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What is Endoscopic Enucleation of the Prostate (EEP)?

Endoscopic enucleation of prostate is a minimally invasive treatment for an enlarged prostate. The procedure involves most commonly the use of  a laser fiber (LEEP) to remove tissue that is blocking urine flow through the prostate. The technical name you’ll find on the internet is either Thulep (thulium laser enucleation of the prostate) or HoLEP (Holmium laser enucleation of the prostate) depending what kind of laser will be used. A separate instrument is then used to cut the prostate tissue into easily removable fragments. LEEP outcomes are similar to open prostate surgery but requires no incisions. In both cases the procedure goal is to remove the entire portion of the prostate that can block urine flow with no incision, like peeling an orange from the inside.

According with the American Urologic Association guidelines can be used for every size of prostate but is a particularly good option to treat a severely enlarged prostate. Because of the large amount of tissue removed, the LEEP provides a lasting solution of urinary symptoms related to an enlarged prostate — a condition known as benign prostatic hyperplasia (BPH). LEEP also preserves removed tissue so that it can be examined in the laboratory for other conditions, including prostate cancer. As with other types of prostate surgery, LEEP can offer faster recovery and symptom relief compared with traditional prostate surgery. Rarely, re-treatment with EEP may be needed for a recurrence of urinary symptoms.

How Does It Work?

Prostate laser surgery is used to relieve moderate to severe urinary symptoms caused by an enlarged prostate — a condition known as benign prostatic hyperplasia (BPH).

During prostate laser surgery, your doctor inserts a scope through the tip of your penis into the tube that carries urine from your bladder (urethra). The prostate surrounds the urethra. A laser passed through the scope delivers energy for a virtually bloodless removal of the obstructing portion of the prostate. The tissue is then fragmented and removed using a different instrument. The procedure is typically an outpatient surgery and a Foley catheter (a probe draining urine through your penis) is typically left in place for 24 to 48 hours and eventually removed in clinic. 

Why Is Prostate Laser Surgery (EEP) Done?

Prostate laser surgery helps reduce urinary symptoms caused by BPH, including:

  • Frequent, urgent need to urinate
  • Difficulty starting urination
  • Slow (prolonged) urination
  • Increased frequency of urination at night
  • Stopping and starting again while urinating
  • The feeling you can’t completely empty your bladder
  • Urinary tract infections

Laser surgery might also be done to treat or prevent complications due to blocked urine flow, such as:

  • Recurring urinary tract infections
  • Kidney or bladder damage
  • Inability to control urination or an inability to urinate at all
  • Bladder stones
  • Blood in your urine

    Laser surgery can offer several advantages over other methods of treating BPH, such as transurethral resection of the prostate (TURP) and open prostatectomy. The advantages can include:

    • Lower risk of bleeding. Laser surgery can be a good option for men who take medication to thin their blood or who have a bleeding disorder that doesn’t allow their blood to clot normally.
    • Shorter or no hospital stay. Laser surgery can be done on an outpatient basis or with just an overnight hospital stay.
    • Quicker recovery. Recovery from laser surgery generally takes less time than recovery from TURP or open surgery.
    • Less need for a catheter. Procedures to treat an enlarged prostate generally require use of a tube (catheter) to drain urine from the bladder after surgery. With laser surgery, a catheter is generally needed for less than 24 hours.
    • More-immediate results. Improvements in urinary symptoms from laser surgery are noticeable right away. It can take several weeks to months to see noticeable improvement with medications.

    Risks of Laser Surgery Can Include:

    • Temporary difficulty urinating. You might have trouble urinating for a few days after the procedure. Until you can urinate on your own, you will need to have a tube (catheter) inserted into your penis to carry urine out of your bladder.
    • Urinary tract infection. This type of infection is a possible complication after any prostate procedure. An infection is increasingly likely to occur the longer you have a catheter in place. You will likely need antibiotics to treat the infection.
    • Narrowing (stricture) of the urethra. Scars after prostate surgery can block urine flow, leading to additional treatment.
    • Urinary incontinence. In a variable number of patient urinary incontinence might occur right after the procedure. The severity of this side effect varies case by case. In most patient this side effect subsides or improve in the long term.
    • Dry orgasm (retrograde ejaculation). A common and long-term effect of any type of prostate surgery is the release of semen during ejaculation into the bladder rather than out of the penis. Also known as retrograde ejaculation, dry orgasm isn’t harmful and generally doesn’t affect sexual pleasure. But it can interfere with your ability to father a child.
    • Erectile dysfunction. The risk of erectile dysfunction after prostate treatments is small and generally lower with laser surgery than with traditional surgery.
    • Need for retreatment. Some men require follow-up treatment after laser ablative surgery because not all of the tissue is removed or it might grow back over time. Men who have Thulep/HoLEP generally don’t require re-treatment because the entire part of the prostate that can block urine flow is removed.

    Serious long-term complications are less likely with prostate laser surgery than with traditional surgery.

    How You Prepare

    Food and Medications

    Several days before surgery, your doctor might recommend that you stop taking medications that increase your risk of bleeding, such as:

    • Blood thinners such as warfarin (Coumadin) or clopidogrel (Plavix)
    • Nonprescription pain relievers such as aspirin, ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others)

    You are likely to be prescribed an antibiotic to prevent urinary tract infection.

     

    Other Precautions

    Arrange transportation because you won’t be able to drive yourself home after the procedure that day or generally if you have a catheter in the bladder.

    What To Expect?

    Before the Procedure:

    Before surgery you will be given either general anesthesia — which means you’ll be unconscious during the procedure — or spinal anesthesia, which means you’ll remain conscious. Exactly what you can expect during and after prostate laser surgery varies depending on the particular type of laser and technique used.

    During the Procedure:

    A narrow fiber-optic scope is inserted through the tip of your penis into the urethra. The laser inserted through the scope is used to destroy, vaporize or cut out the prostate tissue blocking urine flow. Depending on the procedure, your doctor might also use instruments to remove cut pieces of prostate tissue from the bladder.

    After the Procedure:

    You’ll likely have a urinary catheter in place because of swelling that blocks urine flow. If you’re unable to urinate after the tube is removed, your doctor might reinsert the catheter to allow you to heal or give you catheters that you can insert on your own a few times a day until swelling goes down and you can urinate normally.

    You Might Also Notice:

    • Blood in your urine. It’s normal to see blood for a few days to weeks after the procedure. Call your doctor if the blood in your urine is thick like ketchup, bleeding appears to be worsening or blood clots block your urine flow.
    • Irritating urinary symptoms. You might feel an urgent or frequent need to urinate, or you might have to get up more often during the night to urinate. Most men experience burning, especially at the tip of their penis and near the end of urination. With some types of laser surgery, these symptoms can last for weeks or even months depending on how you heal and the size of your prostate.
    • Difficulty holding urine. Incontinence can occur because your bladder is used to having to push urine through a urethra narrowed by enlarged prostate tissue. For most men, this issue improves with time.

    Depending on the type of prostate laser surgery you have, you might go home afterwards or need to stay in the hospital overnight.

     

    Your Doctor is Likely to Recommend That You:

    • Take it easy. Avoid strenuous activity, such as heavy lifting, until your doctor approves it. You might need to wait up to two weeks after HoLEP, but as little as a few days with procedures such as PVP.
    • Hold off on sex. Your doctor might recommend waiting a week or two after the procedure. Ejaculating too soon can cause pain and bleeding.
    • Take medication as prescribed. If your doctor prescribes antibiotics, take the full course.

    Results

    Prostate laser surgery improves urinary flow for most men. Results are often long lasting.

    Sometimes, the laser surgery doesn’t remove all of the prostate tissue blocking urine flow or the tissue grows back, and further treatment is needed. See your doctor if you notice any worsening urinary symptoms.

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    References


    1. Cunningham GR, et al. Surgical treatment of benign prostatic hyperplasia. https://www.uptodate.com/contents/search. Accessed June 4, 2019.
    2. Wein AJ, et al., eds. Minimally invasive and endoscopic management of benign prostatic hyperplasia. In: Campbell-Walsh Urology. 11th ed. Philadelphia, Pa.: Elsevier; 2016. http://www.clinicalkey.com Accessed May 11, 2016.
    3. Nair SM, et al. A review of laser treatment for symptomatic BPH (benign prostatic hyperplasia). Current Urology Reports. 2016;17:45.
    4. Brunkhorst O, et al. Evaluation of the learning curve for holmium laser enucleation of the prostate using multiple outcome measures. Urology. 2015;86:824.
    5. Abdul-Muhsin H, et al. Analysis of benign prostatic hyperplasia patients’ perspective through a third-party administered survey. Urology. 2016;88:155.
    6. Jaeger CD, et al. Holmium laser enucleation (HoLEP) and photoselective vaporization of the prostate (PVP) for patients with benign prostatic hyperplasia (BPH) and chronic urinary retention. BJU International. 2015;115:295.
    7. Laser removal of prostate tissue (HoLEP). Mayo Foundation for Medical Education and Research; 2014.
    8. Photo selective vaporization of the prostate (PVP). Mayo Foundation for Medical Education and Research; 2015.
    9. AskMayoExpert. Benign prostatic hyperplasia. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2019.