HoLEP Experience 2023

Men's health
1

I’ll share my HoLEP surgery experience, done on October 9, 2023.

Have had urination flow issues since age 30. At age 35 a TURP was recommended by a pushy urologist. I’m glad I declined.

25 years later…

Had PAE at age 57 on a 180g prostate, which did not work well, due to an enlarged median lobe. Got Acute Kidney Injury in the process from hospital staff mismanagement of Ibuprofen and Bactrin (antibiotic) after the surgery. Thankfully I recovered from the AKI, I believe through a healthy diet, and exercise.

At age 60 urination was very difficult, though not at the retention level. I was becoming slightly incontinent.

Elected to do HoLEP. My surgeon was very skilled, having performed many HoLEPS, and also realistic and quite kind. He answered all of my many questions.

Planned this, and spent the one year prior to surgery getting fit, especially core and legs, using dumbbells. I’m very glad to have done this work prior and I think that really is helping with a fast recovery.

Ultrasound and cytocsopy prior to surgery revealed that the PAE had shrunk my prostate from 180g to 80g, but the median lobe was quite large, protruding into my bladder, and impeding flow. There was bladder wall thickening.

The HoLEP surgery went well, about one and a half hours on the table, under full anesthesia. Most of my prostate was removed. Woke up and was quickly transferred to a hospital room, and was irrigated with gallons and gallons of water for about 24 hours after surgery, Had one incident of a bladder clot obstructing the irrigation. Surprisingly other than that, there was little pain. Though BCBS considers this an outpatient procedure, my surgeon keeps everyone for 24 hours after for observation and irrigation. My opinion is no way is this an outpatient surgery. I would have been in the unskilled ER no question if he had released me too soon.

At 24 hours the Foley was removed which was a surprise as I had expected to be using it for 1 week. Surgeon said this was because the surgery had gone quite well. Removal was extremely painful. I needed Percocet for the cramping after removal. Pee’d blood weakly after about an hour of Foley removed and terrible cramps. Was released about 29 hours after the surgery.

Went home and slept. Was able to be up a bit the next day and did not feel terrible, as cramping had subsided. Peed a little better, with a little less blood. I think I lost quite a bit of blood, and am trying to eat well to restore it. Eggs, sardines, red meat. Cannot take oral iron tablets because constipation is not something you want going out of this. Was able to poop about two days out, and it really hurt. Stayed in diapers for 3 days.

I’m a week out now and feeling myself again. Flow is OK, defiantly better than before the surgery. No incontinence. Still up many times a night to pee, but I think this is a result of internal inflammation after surgery. Less and less pain on peeing. Erection seems to work, but it is too early to try ejaculation, but expect that to be gone completely. Am hopeful to at least be able to have sexual relations again. Not being incontinent is a blessing, and was what I feared the most from the surgery. No cancer, as the prostate remnants are analyzed, and the cancer markers came back negative. Another blessing.

Today, a week out, I walked two miles, and it was too much, with a little blood in my urine and clots after. Its easy to get over ambitious especially if you are used to regular physical activity.

The surgeon told me to expect continual but slow improvement in flow over 2 months. Grateful for his skill and the availability of this procedure, and hope for a better quality of life than before. Will follow up in a few weeks.

2

Age 62, 55g prostate with high bladder neck and large median lobe. UroLift 9-05-2021 on Lateral lobes only. Going to Mayo next month. This will be my 3rd Uro. I’m looking at a PAE or HoLEP, if the surgeon is experienced in ejaculation preserving HoLEP technique, other wise, I will try and opt for a PAE 1st to see if it helps.

Did you have a high bladder neck?

I ask because there seems to be a direct correlation between a high bladder neck and median lobe size.
This is why I’m leaning towards the PAE. My understanding is the median lobe can be targeted with the PAE as long as its not an Isolated median lobe. If the lateral lobes are tied to the median lobes blood supply, there is a good chance the PAE could work for me.

Obviously, I’m overthinking this, but I want to be prepared for the options they end of presenting me with. If I didn’t have a 5 hour drive one way this might not be as heavy on my mind. I know its hard to ask questions once you leave the appointment.. Tried with my last Uro, 2 months later still no reply.

My friend recently had a HoLEP on his 140g prostate. It went off without any issues and he is doing great..

3

My thinking was try PAE first and if it didn’t work (it didn’t) then move to some sort of TURP (HoLEP for instance.) The unforseen kidney injury due to nurse negligence… Well… that reinforced that any of this is surgery followed by a stay in a dangerous place (the hospital) and it all has inherent and often unexpected risks and complications.

High bladder neck, yes for me, that’s how the urologist described it, and I believe it was getting worse with time despite the PAE. I now know with that geometry; enlarged median lobe and bladder neck protruding into the bladder that PAE was most definitely not appropriate surgery in 2019. Maybe they have improved technique to target the median lobe as you describe? No idea and I got my lifetime dose of radiation! My left and right lobes shrunk enormously. The median where the constriction happened, was basically unaffected.

My understanding is that HoLEP is NOT ejaculation preserving regardless of technique. While they might be able to preserve the ejaculatory ducts, if they remove most of the prostate, there will be no seminal fluid to ejaculate. I don’t think retrograde is the right term. Dry ejaculation would be more accurate. If they preserve some of the prostate maybe different outcome? I certainly don’t want to go through this ever again. My surgeon told me to expect dry and less strong orgasms. Happy for two things - I’m continent post surgery and seem to be able to have erections. No idea about intensity of orgasm yet. The question of continence seems not predictable with worse outcomes for people who go into HoLEP incontinent. But overall, eventual continence seems to happen for most. It just might take awhile, with some pelvic floor therapy.

4

I don’t blame you. I had the UroLift, which is no way as invasive as what you’ve gone thru. That was bad enough. There is a median lobe HoLEP. They don’t touch the lateral lobes, only the median lobe. There is a 2-3% chance of retrograde for that procedure. If they do a HoLEP which includes the lateral lobes, but leaves 1-2 cm of tissue untouched north of the Verumontanum (area of ejaculation ducts), there is a 10% chance of retrograde.

Those with large prostates generally don’t have an option. This is what happened to my friend with the 140 g prostate. The doc indicated that he didn’t have a choice.

I’m hoping my smaller prostate size might give me a better chance at a procedure which doesn’t change my current sexual function.

Thanks for the reply

5

Two weeks out, urination was either fairly good or very bad. At 16 days I went into full retention. Called the surgeon and he saw me right away and I was able to avoid the ER. Scope showed a large bit of sloughing prostate tissue that was somehow acting as a ball valve. Not quite sure I understand the mechanism, but apparently this is not uncommon. He went right in and enthusiastically pulled it off and out with a little grapple. I knew it was going to hurt and we joked about whisky and a rag to chew on first. Came right off, as it was mostly dead tissue. Yes this hurt, a lot. Bled for about a day, but my stream was right away much much better with no ball-valve effect.

One month out. Healing quickly and well, and I am glad I decided to do this. Stream is really good. I think I could p**s my name in the snow. Occasional clots and very occasional bleeding still but that stops quickly and urine is mostly clear. Literally have not pee’d like this since my teens. There is great appeal to overdoing, and I need to watch myself. Can walk about 2 miles on a flat without discomfort or bleeding.

Erection is as good as prior to, and does not seem to have been affected at all. While I can have an orgasm, no ejaculate comes out, nor is any trace in my urine. This is as expected as most of the prostate was removed and there is nothing to generate fluid though my sperm ducts apparently are intact. Not retrograde, completely dry.

I can orgasm, but there is no feeling of release at all any more, just feelingless orgasmic spasms, and I am have a much longer and somewhat uncomfortable refractory period than prior to. Surgeon said this should improve but I have my doubts. This is a loss, but I am dealing with it well enough. Expect to have sex without problem.

Healing is going really fast and well and I attribute it to a full year of core strengthening prior to surgery, the surgeon’s skill, and that HoLEP does less heat damage to surrounding tissue, and minimizes blood loss compared to TURP. I believe things would have been far more difficult if I had not been in really good shape.

Oh, and thank my stars, no leakage or incontinence. I have to get up about once a night (8 hours) to pee and that is a big win.

The surgeon was a champ.

6

Two months out.

Peeing is great. Issues have mostly resolved.

No incontenenance. Some very minor dribbling. Keeping up with the Keagals and will start weight lifting again in 1 more month.

Erection is fine, so PIV sex is possible. Orgasm happens - spasms but no pleasurable sensation or feeling of release, and sometimes orgasm actually hurts. No semen - not retrograde ejaculation, it is fully antegrade.

Overall I am very happy to have done this. I seem to be coping with the side affects well, and partner has been very supportive - women have their sexual issues at age 60 too.
I feel like I am done with prostate problems, and that is a big relief.

7

so, you are getting, what is called, a dry ejaculation, which means you are not producing semen, as opposed to retrograde ejaculation, where you are producing semen but it flows back into your bladder.