Holmium laser transurethral enucleation of prostate adenoma (HoLEP)

Like any surgery, Holmium laser enucleation of prostate adenoma (HoLEP) is also associated with some possible complications.
The possible complications related to the endoscopic surgical procedure, in addition to the generic risks related to anesthesia, are the following:

• Bleeding during and after surgery which may require re-operation for diathermocoagulation of the prostatic bed

• Acute urinary retention requiring repositioning of a urethral catheter

• Transient urinary incontinence of various degrees

• Late bleeding i.e. in the two or three weeks after surgery, caused by the detachment of the eschar

• Bladder neck sclerosis: late narrowing of the bladder neck which may require further endoscopic revision

• Urethral stricture: late narrowing of the urethral canal which may require further endoscopic surgery
Blood in urine.

Urine may remain pink for up to 3-4 weeks. Sometimes we observe the leakage of small clots that were present in the bladder. If this happens, drinking plenty of water can help make your urine clear again.
Irritative micturition symptoms. In the first days or weeks following the treatment you may experience the need to urinate frequently, the presence of urinary urgency and slight burning in urination, for which appropriate medical therapy will be prescribed.
Urinary incontinence of various degrees. Some patients complain of little urine loss in the first weeks after surgery. This can manifest itself with the simple loss of a few drops after an effort (sneeze, cough, etc.), or be of a greater entity and such as to determine, in some cases, the use of a diaper. This situation is transitory and destined to improve over time, until it resolves itself.
These rare cases of urinary incontinence present immediately after the operation can be partly attributable to some behavioral changes present in the period preceding the operation. During this period, the obstruction created by prostatic hypertrophy often forces the patient to go to the bathroom frequently (even during the night) and to “push” with the abdomen, forcing the bladder to empty.
After removing the anatomical “plug”, the patient must quickly change his behavior, paying attention to the bladder filling phase: it will be necessary to “teach” the bladder again to fill and empty at regular intervals of at least 3/4 hours, not to push during urination, to hold back even in situations during which strong stresses come on the bladder, such as a cough or an intense effort.
All this can be achieved more quickly through a rehabilitation management, which therefore provides for learning the correct introduction of liquids (deduced from the body mass index, physical activity, eating habits of the patient), the voiding intervals to be respected to recondition the elasticity that the bladder has lost during the period preceding the operation and muscle training aimed at the pelvic floor which is usually weakened by the continuous pushes performed over time by the patient to empty his bladder better.
Behavioral information regarding the bladder or “bladder training” is normally suggested by the expert therapist, after an interview with the patient and the possible compilation of a bladder diary. During the same meeting, exercises are also suggested aimed at improving the tone and strength of the perineal muscle (which is often also called the “pelvic floor” precisely because it closes the abdominal cavity at the bottom and supports the viscera), identifiable with the lozenge-shaped muscle area that is placed on the saddle when riding a bicycle.
Rehabilitation treatment aims to strengthen these muscles, improve their strength and their constant “holding” throughout the day, in relation to breathing and increases in intra-abdominal pressure, precisely to facilitate the normal return to bladder continence capacity and the possibility of keeping the bladder full in situations where a toilet is not immediately available (urgency-frequency symptoms).
Post-operative rehabilitation consists of different techniques, depending on the problems present:

– voiding education, or “bladder training”: sharing of suggestions relating to lifestyle, the modality and quantity of drink intake: these suggestions are personalized on the basis of the compilation of a voiding diary, filled in by the person himself for at least two consecutive days, where the liquids ingested, the urinations performed and any fuss must be meticulously marked
– kinesiotherapy for strengthening the perineal muscles: series of exercises aimed at training the perineal muscles, specifically the one found between the anus and the scrotum, around the penis. Not the contraction of the anus, since this turns out to be substantially useless for the control of urinary continence. Depending on the recovery obtained, the exercises can become increasingly demanding, up to being performed with the telemetric Biofeedback technique (with anal manometer probe) during the execution of more demanding physical activities (jumping and running on the spot)

– Biofeedback: allows you to view muscle activity on the computer screen, making it easier to identify errors in performing a single exercise and correct them

– in particular situations Functional Electrical Stimulation is used, which has as its objective not only the strengthening of the muscles, but the awareness of the perineal plane and the possible inhibition action on the contraction and emptying of the bladder through the use of currents that are directed directly onto the muscle through anal probes with ring electrodes, or surface electrodes

– PTNS (Percutaneous tibial nerve stimulation), a technique that involves stimulating the posterior tibial nerve using an acupuncture needle; this technique is particularly effective for symptoms of urge incontinence or frequency urgency syndromes without incontinence.

The rehabilitation treatment therefore supports the pharmacological medical treatment in dealing with post-intervention problems and represents an effective way to improve the patient’s quality of life and accelerate the recovery of bladder function.
Sexual function. Almost all patients undergoing HoLEP report an improvement in the quality of their erection postoperatively. This is believed to be induced by the marked improvement in urinary complaints.
About 80% of patients undergoing this surgery lose the ability to ejaculate seminal fluid from the urethral meatus during sexual intercourse; as a result of the anatomical alterations resulting from the operation on the bladder neck. The seminal fluid therefore collects in the bladder and is then eliminated during subsequent urinations (retrograde ejaculation). It is important to underline that the orgasm is always maintained (i.e. the sensitivity does not change).
It is important to remember that often a small amount of seminal fluid can still flow antegrade from the urethral meatus during ejaculation. This intervention, therefore, does NOT lead to post-operative sterility.