Laser technology has lowered complications for this very common procedure, allowing patients to heal at home
By Amy E. Krambeck, MD
Benign prostatic hyperplasia (BPH), or enlarged prostate, is exceedingly common, affecting half of men in their 50s and about 90% of men aged 80-plus (American Urological Association, 2019). As a result, although most patients are treated with medication, surgical procedures to treat BPH are very common as well, making up a significant portion of urological surgeries in any hospital.
With any BPH procedure, tissue is removed to open the urethra. Patients typically stay at least one night in the hospital. There has been a successful ongoing effort to reduce inpatient time for BPH surgery by limiting complications, especially postoperative bleeding.
At my Level I trauma hospital, which runs near capacity at all times, sometimes beds were not available for my patients, and they had to spend the night in the recovery room. We postulated that we could free up beds and offer better treatment for our patients by performing BPH surgery on an outpatient basis. Because we were performing very safe surgery with the latest laser technology, it seemed we had finally reached the point where it was safe to send patients home.
Transitioning to outpatient surgery
Patients with BPH who undergo transurethral resection of the prostate (TURP) or suprapubic prostatectomy stay one or two nights in the hospital with a catheter irrigating the bladder to prevent clots from forming. We began performing holmium laser enucleation of the prostate (HoLEP) with a 120-watt holmium laser that modulates the laser pulse (“the Moses effect”) and specially designed fibers that, used together, allow us to remove tissue more efficiently for shorter procedure time. Compared to other HoLEP technologies, the system has shortened our HoLEP cutting time by 30%–40% and reduced cautery time by 50%.
The procedure causes much less bleeding during and after surgery compared to alternatives like TURP. The modulated laser pulse delivers energy to the tissue more efficiently, without scatter, and cuts and coagulates simultaneously. Because HoLEP produces so little bleeding, we found patients’ urine was almost clear after surgery. They did not need irrigation overnight, thus it appeared that we could send them home the same day with a catheter.
We did not take this change lightly. We spent three months following nearly 100 patients from check-in to discharge, gathering data about our process. Satisfied that we hadn’t overlooked any advantages of the hospital stay, we sent the first HoLEP patients home the day of surgery, and we have done so for virtually all patients for the past six months. We place no restrictions based on prostate size or use of anticoagulants, but we still keep patients overnight if they have acute comorbidities.
Patients go home with a catheter, the home care for which is explained by medical assistants using an educational template. The catheter is removed the next day in our office or, if the patient has traveled for surgery, at a physician’s office closer to home.
Better for patients and the hospital
Aside from reducing patients’ stress after BPH surgery by allowing them to convalesce at home, HoLEP has significant advantages for our patients. Transurethral HoLEP has one of the lowest postoperative morbidity rates of all BPH options, the least blood loss, the shortest catheter time, and lower retreatment rates (Kuntz et al., 2008; Gilling et al., 2012). Short catheter dwell time means lower risk of urinary tract infection compared to TURP (Cornu et al., 2015).
Anecdotally, we’ve seen that our HoLEP outpatients tend to do better than inpatients for any BPH procedure. When we remove the catheter the next day, they are more likely than inpatients to successfully urinate. We speculate that this is because patients move more at home than they do in the hospital, where they also may receive narcotics or other medications that can affect urination.
Moving to outpatient surgery also lowers healthcare costs. We’ve opened up beds in our hospital for other, more critical patients. None of the BPH outpatients have presented to the ER with surgery-related complications. It’s a tremendous savings, particularly when multiplied for such a common procedure.
My colleagues and I are now tracking the outpatient program so we can compile data, but at this point, it appears to be a success. I think in the future, patients are going to insist on getting HoLEP not only because of its clinical advantages, but also because they can go home the same day. They don’t want significant bleeding and prolonged catheterization after BPH surgery; they want to get back on their feet quickly, without complications. As more surgeons performing HoLEP shift from inpatient to outpatient BPH surgery, hospitals will no doubt help drive this change as well.
Amy Krambeck is the Michael O. Koch Professor of Urology at Indiana University School of Medicine in Indianapolis. She is a consultant for Boston Scientific and Lumenis.
American Urological Association. (2019, May). Benign prostatic hyperplasia (BPH). https://www.urologyhealth.org/urologic-conditions/benign-prostatic-hyperplasia-(bph)
Cornu, J.-N., Ahyai, S., Bachmann, A., de la Rosette, J., Gilling, P., Gratzke, C., McVary, K., Novara, G., Woo, H., & Madersbacher, S. (2015). A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic obstruction: An update. European Urology, 67(6), 1066–1096. https://doi.org/10.1016/j.eururo.2014.06.017
Gilling, P. J., Wilson, L. C., King, C. J., Westenberg, A. M., Frampton, C. M., & Fraundorfer, M. R. (2012). Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: Results at 7 years. BJU International, 109(3), 408–411. https://doi.org/10.1111/j.1464-410X.2011.10359.x
Kuntz, R. M., Lehrich, K., & Ahyai, S. A. (2008). Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. European Urology, 53(1), 160–168. https://doi.org/10.1016/j.eururo.2007.08.036