My HoLEP prostatectomy

Hi Pete, stay with us for a bit as we will all have questions:-)

I had PVP for 75grm prostate in 2005 and It had grown to 125 grams by the time I had Thulium laser last year at age of 79.

In what way is HoLep better than Thulium laser?

Last year my surgeon called PVP a commercial procedure and not a cure? One of the first surgeons to do PVP in this country told me a few years ago that they thought that PVP was a quick and simple procedure but they later realised that it needed more time and care.

We are puzzled by post-operative bleeding. If the laser seals as it goes along there should not be post-operative blood. If blood goes into the bladder during the procedure it would be washed out in the theatre.

Some patients pass a lot of blood clots and debris and some very little. We are warned that we may pass clots as long as six months later.

Last year the urology nurse who removed my catheter said that post-operative blood comes from the urethra which due to trauma inflicted on it swells up like a sponge and absorbs blood.

After each procedure my flow has been much less than expected. How general is that. At my follow up visit the surgeon offere to have a look but I decided to leave well alone as two people I know had follow ups after TURPs that did more harm than good.

Finally do you subscribe to the advice of many surgeons that patients should  take Avodart forever after surgery to prevent the prostate from growing again? 

Pete, if you will, please your opinion of the proposed solution to my BPH; i'm 76, all vital signs about perfect,  physical condition better than most 50 year old men due to strong hereditary factors, diet, exercise, etc. BPH meds have run their course and a surgery of some sort cannot be avoided any longer.  

My long-term urologist, head of urololgy at a major hospital, says my prostate, 114 mg with a third lobe, is beyond the scope of turp or laser and recommended simple prostatectomy by one of his specialist colleagues. I declined the procedure as it stretches the bladder opening and I fear incontinence which he states is likely to be a problem.

I saw a third urologist, also very prominent in Texas. He proposes turp to remove the third lobe, see if this is sufficient and possibly Urolift if necessary later. He is a pioneer in the Urolift method and uses it a dozen or so times monthly for smaller prostates with no third lobe. . I asked him about HOlep and he states for my condition turp would be preferable although PVP is also an option. He does not use the Holep method and states that no uros in his city of two million uses it.

I want to get off all meds and see if i can get my active sex life back.    

I was on the verge of accepting his solution for immediate action until reading your post here today.  As you know getting an unbiased opinion is very difficult  Can you comment?

Thanks, RonTexan 

Pete is a good person to seek advice from. Try Dr James Lingeman out of Indi too, he has done the most in the US and will communicate via email with you. Just call his office. I do not think the Texas urologist is being completely objective, simply because he doesn't do the procedure so he isn't incentivized to endorse it, because I was told similar things by Chicago urologists who all wanted my business using the TURP method which I already had and the relief only lasted ~15 mnths, because HoLEP is probably perfect for your conditions (again, ask Pete and James Lingeman to validate), and because I think there is at least 1 or more doctors in Dallas doing the procedure (google it online, I did). Travel if need be. I traveled from Chicago to Indianapolis to see Dr Lingeman. It was worth it. I haven't seen a urologist since, 2-3 years later, no need to.

Thanks Bill, it is just dang difficult to make a choice among so many options and opinions. I can't decide like I would buying a new automobile. This is my life and judging by my forebears I have another twenty years if I don't make bad decisions. So far, acceptance of meds as my solution has been a bad one, I should have had turp or some other ten or twelve years ago and refused any meds. I would probably not be trying to get my sex life back now.  I can't afford another bad decision.  

Hi Ron,

Just looking from the outside, it seems like holep may be the best choice because it has the benefit of the simple prostatectomy which removes the most tissue, but does so in the least invasive manner, like the pvp laser.

You need to do your due diligence, but if I needed another procedure, I'd be looking close at the holep, getting as much info as I could on it.  That said, one person on another board had a holep in Australia, the same time I had my Greenligh laser. He had to go back 6 months later for some cleanup. I needed to go back 6 months later as well to get some scar tissue (a membrane grew back, blocking the urethra) which was removed with the cystocope without anesthesia. Then a year later I needed a bladder mouth resection (widening) removal of stones and cauterization of three bleeders on my prostate and bladder neck. I rolled the dice with the GL and realized it's far from a permanent solution. But my issues of bladder neck, bladder stones and hematuria are not that uncommon and could occur with any procedure including a radical prostatectomy. There's no magic bullet as far as I can tell. 

You're right, it's a roll of the dice regardless. All you can do is investigate and  investigate some more. Then when all the data, opinions, hype, sales talk, legitimate information, testimonials, good and questionable advice etc have been considered hope that the surgeon is having a good day and his equipment is working properly. (Because your equipment is not going to if his isn't !) 

My God, there is a best solution somewhere. I agree that Holep sounds really good but almost nobody in Texas uses it. Apparently, there is a real learning curve compared to something like Urolift. Do I want to travel 200 miles or more for the procedure to be done? I don't know, but I know I'll have to figure this thing out pretty soon.

I'm not much good at rolling the dice, nor at drawing to an inside straight. I'm more of a bet the farm on at least a full house kind of guy. Else fold and wait for the next hand. Due diligence proceeds at a healthy pace. Again, I appreciate your input and all of it in this forum.   

Well, I have researched the Holmium Laser Enucleation, Holep procedure well enough to satisfy myself that it is the procedure I want to be performed on my prostate. Here's a quote from a study conducted last year which pretty much says it all.

"As the first endoscopic enucleation procedure for BPH, HoLEP is a paradigm shift in BPH surgery. There is a significant level 1 evidence base to support it, and it is the only BPH procedure to have demonstrated better symptom relief, greater urodynamic improvement and greater durability than TURP. It is safe and effective for prostates of all sizes, men in urinary retention and those who are anticoagulated or have bleeding disorders. HoLEP, therefore, is a valuable addition to the modern BPH surgery armamentarium."

That is not the only study result I found that says the same thing, just an example of the results of several studies. Pretty conclusive to me!!

Here's the part that I do not understand; Holep is not new, it's been around for at least a decade, it has been recognized that long as superior to turp, any other laser technique,  or any other BPH surgery you can name. (I still think Urolift is superior in the few years term for those patients who qualify!) and yet Holep is is not performed universally as you would expect or not even commonly. Rather, there are only a handful of urologists in Texas who perform the procedure.  So, what is the reason for this? Apparently the learning curve is stiff and many urologists don't want to get up to speed, especially since turp works just as well from the DR's point of view, since he/she is not enduring the increased blood, pain, catheters, hospital stay, extended recovery time, more-likely need for a repeat procedure, more likely permanent ED, more likely need for meds forever, etc etc.

I saw some reference also to increased cost of the procedure compared to other methods. I therefore suspect that insurance companies pressure urologists to perform turp since they don't care about the patient's blood, less efficacy, more and extended pain and long recovery times either. Just costs less so do it. Wonderful.

From the patient's point of view there's no comparison, it's Holep hands down regardless of the size of the prostate and I am going to find a way to have this procedure done. Looks like I will be driving 200 miles to Dallas as that is the nearest location I can find so far.  Wish me luck.   

In 2004 when I asked a urologist in Edinburgh to refer me for PVP I had a letter from a hospital in Dundee offering me Holmium Lader surgery. I turned it down as I felt that it was not as precise a procedure as the PVP that took me another year to get.

I expect that Holmium laser was an early version of HoLep.   

Ron I think you're making the right decision. You and your prostate (size and lobes)make you a great candidate for HoLEP.  Don't expect an overnight cure- the full benefits may take 2-3 months to materialise whilst things settle down ie your bladder gets used to the new arrangements so to speak, but I think you'll feel much better for it before too long. Best of luck and let us know how it goes. 

Pete. 

Hi Ron,

Looking forward to your updates on this. In your shoes I'd be looking to go with the holep as well.

Bob

Thanks so much, all of you who have been loyal sources of information and support for the several months I have studied my condition to exhaustion in pursuit of what I believe is the best solution in both the short and the long run. Your opinion, Pete, is recognized as an expert opinion and one we don't often see in the forums. Thanks!

Now i have to find a urologist to perform the surgery. I intend to contact Dr Claus Roerhborn's office in Dallas tomorrow. One thing that is obvious about the few Urologists who perform the Holep procedure; they are all prominent and preeminent in the field in their cities.  I.e. there's no rookies doing this procedure.  Dr James Lingeman in Indiana would be another good choice, but that's a least 1200 miles and I don't see getting on an airplane to get back home. Dallas is about three hours driving time, guess I can handle that, riding not driving.

I'll let you know the steps as i take them.

Thanks, again

Ron    . 

 

I don't see flying post surgery as a problem.

Patrick who used to post on a BPH NG was the first person to ever have PVP and within afew days flew from America to Japan, 

Could work out ok but a three hour drive is just over the horizon in Texas and I'm planning to stay in the City for a few days just in case. I know I'm a wuss, but after 76 years of pushing myself I'm going to take it easy for awhile. Whomever is depending on me can just do it themselves for a few days. I may go watch the Cowboys lose again while I'm there. 

My last post was very upbeat as I thought I had found the solution but not so fast, here we go again. Another roadblock in the path of getting the best solution I can find.

I believe I am discovering that Holep is best for the patient (me) but not so great for the Docs who perform the procedure. Appears that Holep involves extensive training at the side of a very experienced mentor. Many times the experience required to learn a simple procedure like urolift, for example. The most experienced uros doing the procedure currently trained with Dr Lingeman in Indiana. He pioneered the procedure in the US and the result of his training is legendary.

I found two Drs who had performed the procedure in Dallas and was confident, as posted here,  that one of them could do the Holep procedure for me. Not a chance!  Both have quit doing the procedure. I spoke to the nurse of one of these prominent urologists and she stated that the results of Holep were just was not as satisfactory to the patient as Turp so her Dr only performs Turp.

I have read several clinical trial comparisons of Holep vs Turp and in considering (1) the likelihood of future problems requiring more surgery (2) likelihood of continued use of meds, (3) length of recovery time (4) eventual satisfaction of patient's condition etc, ad infinitum, Holep wins every time.

So, have these Doctors quit the procedure (and a real shortage of Drs doing Holep resulting) for reasons affecting patient satisfaction or is it the steep learning curve, the required extreme experience required, a liability insurance factor, expense of the equiment or that Holep is a one-stop-forever solution if done properly and the Dr  never sees the patient again?  

Or what else is the reason that so few doctors are doing the procedure?.  I don't know but Dr Lingeman has a five month wait for surgery; three months to get a consulting appointment and another two months for the procedure to be done, assuming that the patient qualifies, of course. I have heard that one of the uros he has trained is not taking new patients. I have not confirmed that, though.

So, there appears to be no uros in Texas performing the procedure that I can find, I have heard of none in Louisiana, Oklahoma, New Mexico, Kansas, Arkansas, etc. The closest is probably in Arizona. None in driving distance of less than two hard days.

If I had descovered Holep back in April when I was pursuing Urolift I could have got on Dr Lingeman's or one of the other's schedule and I would have had the Holep procedure done by now.

Now I am very dependent on Jalyn to keep my BPH under some sort of control but I see it becoming less effective and I doubt that it will keep me continent for five more months.  I think that at some point  I will be self-cathing although I tried and couldn't do it to the point of pulling out a bloody catheter.  

Can any of you who have had the Holep procedure done point me to a Uologist who can perform the procedure in a shorter time? It's beginning to look bad for me.     

Contact Lumenis the makers of the Holep Equipment and ask for urologists using it in Texas.

I hesitate to suggest this, but here goes: why not fly to the UK and have it done here? My uro says he does at least two HoLEPs a week and has done lots - I specifically quizzed him about this (as well as checking the hospital tha they did indeed use a HoLEP). The cost was £5.5K = $9K?. But I don't know whether you can afford that or your insurance will cover it.

Believe me, I have considered that. I have Medicare with a supplement policy which pays literally everything for seniors, Medicare  costs my wife and I $3180 per year and is a great bargain considerinfg the care we get.  I don't believe medicare will cover foreign surgical care but I could check on it. I will check with Lumenis but you not only have to have a Uro who does the procedure, you really want one with at least hundreds of Holeps on his resume. No place for rookies. The quest will continue unabated. 

I would puruse Lingeman. Just tell the nurse you will take the next cancellation. It will happen, for the appointment, and for the surgery.

I believe a woman out of Mayo in Rochester does HoLEP and was trained by Lingeman. You can find her and others online.

Pete, your post was very instrumental in my choosing the Holep procedure. I contacted Dr Humphreys at the Mayo Clinic in Phoenix, AZ and had the procedure done on 10-31-14. of course I knew that the Mayo clinics were tops in the US and my experience bore that out. 

When I awoke from surgery the nurse asked me for the scale of 1 to 10 the level of my pain. I replied "maybe 1 or 2, there's really just a little discomfort". So she gave me no pain medicine and I never had any. They gave me a prescription for pain but I never filled it. I had pink urine for a few days and a bit of burning, nothing painful, for six days. Since my bladder orifice was stretched out by a protruding third lobe I was totally incontinent for a few days and wore Depends Real fit home two days later,  traveling through three airports carrying my bags for six hours from Arizona to Texas. 

I am 76, in good shape, and I have had sprained ankles that were much more painful and debilitating than this surgery. Today is the 11th day, I've had no irritation or pink urine for about four days, and I am no longer incontinent. I still wear the Depends but they are completely dry at the end a 16 hour day. I have not done any of the Kegel exercises as I could see that I was progressing and I didn't want to irritate anything. Now I get urges to go every 3-4 hours, no urgency, I can wait a half hour if i want. My stream is strong and complete, I'm sure I'll be knocking the bark off a tree in a week or two.

In short, I expected a good outcome but I had no idea how easy it would be. I am literaly overwhelmed, beyond belief. 

I owe you one, Doc, if you are ever in Central Texas, I'll treat you to barbecue standing ribs at Cooper's in Llano. It doesn't get any better than that. Sort of like the HOlep procedure and your advice. 

Ron In Texas 

 

Ron, I follow your posts with great interest. You seemed well informed and someone who did a lot of research before making a decision. I am 61, live in Dallas and in the early stages of my decision -making process.  I’m considering to be evaluated for UroLift or maybe go for HoLep.   Not sure if there is anyone that you may have come across with good credential in the Dallas area.  My prostate is 38g, but the symptoms are severe.  My PSA is 2.7.  In the last five months, I had to go to ER 6 times for a catheter. For UroLift, I am considering contacting Dr Kella to see if I qualify.  I understand that you are happy with both Dr. Humphrey and  HoLep.  Can you please describe the evaluation process and how long it took from the evaluation to surgery.  Any other suggestions and thoughts you wish to share are most welcome. Thank you!

Hi Garry, you've come to a most informative place, there are a number of other forums in the Prostate Problems Group; Non-invasive BPH treatments I'm considering, Possible BPH - looking for advice, Self-catheterization, alternative to Turp, greenlight, holep... etc. lots of real-world experiences, discussion of options, some of which you have never heard of and some you'll discard out of hand.

Every guy has a prostate and most of us are willing to talk about some really personal things. I've revealed details on these forums that i wouldn' t tell my Dr or my mother.

Anyway, medical science marches on, new revelations almost monthly appear in these forums. 

I would have had urolift by Dr kella in a heartbeat but my prostate was 114 mg and had the third lobe, either one disqualifications. At your age and prostate size i would expect Urolift to work well. But understand that urolift does not remove any tissue and prostates continue to grow, chances are urolift will work fine for a few years but there's probably another procedure in your future. I saw it as a way to buy time. 

Holep was practiced by a urologist in the Dallas area but he doesn't anymore. I forget his name. There aren't any more in Texas, LA, OK, NM,  I'm pretty sure. My Doc as you know is at the Mayo in Phoenix

As far as the evaluation process is concerned, I think it was a foregone conclusion that I was going to have Holep when I arrived at the Mayo. I wanted the procedure, they could do it so that was it. Actually, Holep can be performed on any prostate of any size or configuration so the qualifying was easy. 

I think that the point of the extensive interviews by the most interesting and brilliant young women docs I have ever met, by the way, were to find if there was any psychological reason to disqualify me. They knew all of the physiological issues from exams done by Dr Kella and two other Uros in Texas so they knew I would qualify.

In timing, I arrived alone on Wednesday AM, had exams and meetings that afternoon, more meetings and exams thursday, Doc Humphreys did the cystoscope and rectal ultrasound himself, that was impressive. Surgery was friday am, Oct 31, 2014, at 7:30. It took maybe an hour to hour and a half and i awoke in my room in a couple of hours. The nurse asked on a scale of one to ten how much pain,  i said 1 or 2, not much so she gave me no pain medication and I never had any to date. I stayed in my room for 24 hours, my son came saturday and checked me out. They had asked that i stay at the Hotel on campus for a couple of days just in case and my son stayed with me.

The next day, Sun, we took a driving trip up in the mountains to a mining town, walked all day and had no problems other than I was incontinent due to that the third lobe had protruded into the bladder. I dealt with that with Depends, extra absorbant. see, we tell everything here.

 

Here are some things I have learned and some conclusions drawn;

Urolift is probably not a long-term solution and I would not have it done after all I have learned in the past 6-8 months. There are more permanent options. 

If the number of dissatisfied posters in these forums is an indication i would stay away from green light laser.

Turp is the gold standard for Doctors because it is fairly easy, works most of the time, is done fairly quickly, lasts for 6-9 years maybe,  and the patient will eventully be ok.

Holep, turp, greenlight laser, Thullium laser and any other method that removes tissue to create a path thru the prostate will cause Retrograde Ejaculation in all probabilty. They may cause erectile disfunction as well. I haven't had a problem but many others have. I feel certain that ED will be minimized with Holep compared to the others but every case is different. I also feel certain that Holep is likely to last longer and i know for a fact that Holep is performed by the fineist urologists in the country with the best supporting staff and in the fineist medical centers. My Mayo Clinic experience was a wonder for a guy who hasn't had surgery since 1944.

I think the quality of my Mayo experience went a long way toward minimizing the danger of errors in the operating room, liklihood of infections, misapplied anesthesia, and just poor care in general. As I have stated injury and death in hospitals are rampant in our country and i will never have any procedure done anywhere other than at the Mayos. Johns Hopkins, or Major University Medical Centers, period.   

I was as scared of surgery as anyone else and I put off a surgical procedure by stuffing my body with every pill available for ten years and until they just didn't work anymore. This caused RE, kept me on the verge of ED, taking testosterone shots to keep active, etc. Holep met my needs perfectly and was no more invasive than urolift, but I'm 76, the meds gave me RE years ago, my sex life is ok at my age but 16 years ago I would have seen it entirely differently.   

Knowing what i know now, at your age, I would read the other forums and the posts about PAE, a couple of patients have had great sucess with no side effects with that new-to-urology procedure.

I wish that I had learned to self-cath ten years ago so i would have never taken one of the meds that cause such permanent damage. Anyone could avoid trips to the ER if they just gut-up and do it themselves. 

You probably read that I did finally learn how, it's not difficult and although i never had to use it I knew that I could if necessary. Read this thread  " self-catheterization - an alternative to TURP, Greenlight, HOLEP. The originator of that thread, JimJames, uses no other method and hasn't for years. He has no pills, no RE, no ED, no surgery, etc. He has found, at least for him, the perfect way to buy some time waiting for new developments in technology. I know that i could do that if I had to and I would if I was young enough that a strong sex life was a daily necessity.

Many thousands of sufferers read these posts, your experience can help others if related here. It is an incredible medical resourse. 

Good luck, Garry, post again if I can help.

Ron  

.  

Hi Ron, I have read your posts and was wondering if you still feel your holep outcome is good after many months now? I have been considering the Mayo in Phoenix with Dr. Humphreys for the same procedure. Any comments would be greatly appreciated.

Hi John. No, nothing has changed.  It's been about 3.5 months and I am still amazed that there was just a bit of discomfort for 7 days or so, no actual pain and I'm not pain tolerant by any means. Pink urine stopped at the same time and at that time I consider it a complete recovery. 

As you know, my third lobe was protruding into the bladder substantially and had been for a dozen years or so. When the prostate was removed from the bladder neck I was completely incontinent and I still have to be a bit careful now although it continues to improve without any kegel exercises on my part.

I get a normal urge to urinate every few hours depending on fluid intake and I have no problem holding it for twenty to thirty minutes, just like normal. I'm so accustomed to getting up at night that I still wake about 3:30 or so every night, get up and go, whether I really need to or not, and get back to bed, sleeping until 7 -7:30 usually.

I really don't have a stream, it's more of a flood, I'm not kidding, the stream is so full that I really have a bit of difficulty directing it accurately, sometimes I need to get right over the toilet as it's not going very far and when it stops it's like shutting a fIaucet, no dribble, no stopping and starting, just empties the bladder in 10-12 seconds and stops right now. There is never any sensation of not emptying my bladder, it empties completely very quickly. Pretty amazing. There's really just not anything blocking the flow. But you know it was almost this way after only seven days, there's been maybe a 10-15% improvement since then and i would have been very satisfied if there had been no change later. Only the incontinence has lessened and that's ok now if I pay attention to the urges when they occur.

My sex life is better than before the surgery but not like twenty years ago. Again, it's acceptable for a 76 year old.        

The Mayo is an incredible place, just bright, professional faces everywhere and an air of complete confidence in everyone. I stayed at the hotel on campus and walked a quarter mile or so through the desert to get back and forth. They have a shuttle to take you with a very short wait but I enjoyed the walk. The shuttle will take you 2 miles in any direction and there is a huge shopping mall within distance. You can have them drop you off and call them to pick you up later. Another shuttle takes you from the airport to the hotel.

They require that some adult be with you the next morning after surgery to check you out as you are not supposed to carry anything although I did without difficulty. They also want you to stay in the hotel for a couple of days just in case. My surgery was Friday AM , checked out Sat AM, stayed at the hotel eating at the hospital cafeteria mostly until Sun AM my son and i rented a car and drove up to Jerome. A fascinating place, be sure to see the old truck collection, you'll have to ask where. Totally, amazing to an old truck nut like me.  

All together, it wasn't like any major surgery I had ever heard about, nothing like setting a broken bone, nor like having tonsils out. Here's a comparison; I had balloon rhinoplasty done to my sinuses a few years ago to open them up and maybe that was sort of the same severity. Just not anything much.  

Here's something to be aware of, if you have a third lobe in the bladder you'll have to wear some sort of pad, Depends Extra Absorbency is the best but you have to wear the darn things and what the hospital supplies is totally embarrassing. Take your own. Here's what I did when I got home. I bought several pairs of stretch sport shorts, you know with no fly and really tight and stretchy but comfortable. I took the Depends and cut the pad out and threw the rest away, then stuffed the pad down where it needed to be and I'm good to go. I would still use these if I thought I was going to be away from a bathroom for several hours.   

So, if your experience is anything like mine, it just can't be a better major surgery experience. 

Best of luck to you and I would really like to hear how your solution turns out. Ron

Hi Ron...I just posted quite a bit on information on this forum...if you have time and you're still following this forum, please check it out.  Just like you...I've scheduled the HoLEP procedure at Mayo, Phoenix.  I'd be very interested in your responses to my questions in that previous post.  I reside in NM since '77 but, born and raised In TX, attended TAMU and TTU.  Looking forward to hearing from you and other members of the forum!