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Prostate laser surgeryBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/prostate-laser-surgery/MY00611
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 urethra is surrounded by the prostate. A laser is passed through the scope. The laser delivers energy that is used to shrink or to remove the excess tissue that is blocking the urethra and preventing urine flow.
All lasers use concentrated light to generate precise and intense heat. Laser surgery removes excess prostate tissue by:
- Ablation. The laser melts away excess tissue.
- Enucleation. The laser cuts away excess prostate tissue.
There are different types of prostate laser surgery, such as:
- Photoselective vaporization of the prostate (PVP). A laser is used to melt away (vaporize) excess prostate tissue to enlarge the urinary channel.
- Holmium laser ablation of the prostate (HoLAP). This is a similar procedure to PVP, except that a different type of laser is used to melt away (vaporize) the excess prostate tissue.
- Holmium laser enucleation of the prostate (HoLEP). The laser is used to cut and remove the excess tissue that is blocking the urethra. Another instrument, called a morcellator, is then used to chop the prostate tissue into small pieces that are easily removed.
The type of laser surgery your doctor will perform depends on several factors, including the size of your prostate, your health, the type of laser equipment available and your doctor's training.
Why it's done
Prostate laser surgery helps reduce urinary symptoms caused by BPH. Urinary symptoms caused by BPH can include:
- Frequent, urgent need to urinate
- Difficulty starting urination
- Slow (prolonged) urination
- Increased frequency of urination at night (nocturia)
- Stopping and starting again while urinating
- The feeling you can't completely empty your bladder
- Urinary tract infections
Laser surgery may 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 (incontinence) or an inability to urinate at all (urinary retention)
- Bladder stones
- Recurring blood in your urine
A number of procedures are available to treat BPH, but laser surgery has several potential advantages over other methods, such as transurethral resection of the prostate (TURP) and open prostatectomy. The advantages generally include:
- Lower risk of bleeding. Because there is a low risk of bleeding with laser surgery, it 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. Other prostate treatments, such as open prostatectomy or transurethral resection of the prostate (TURP), may require a longer 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, while it can take several weeks to months to see noticeable improvement with medications.
Serious long-term complications are less likely with prostate laser surgery than with traditional surgery. Risks of laser surgery can include:
- Temporary difficulty urinating. You may 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. Urinary tract infections are a possible complication after any prostate procedure. An infection is increasingly likely to occur the longer you have a catheter in place, and may require antibiotics or other treatment.
- Narrowing (stricture) of the urethra. Just as you can form scars on the outside of your body, you can form scars on the inside after prostate surgery. These scars can block urine flow, requiring additional treatment.
- Dry orgasm (retrograde ejaculation). Any prostate surgery can cause retrograde ejaculation, which means semen released during sexual climax (ejaculation) enters your bladder rather than exiting the penis. Retrograde ejaculation isn't harmful, and generally doesn't affect sexual pleasure. But it can interfere with your ability to father a child. This is a common long-term side effect of procedures to treat an enlarged prostate.
- Erectile dysfunction. There is a small risk that ablative procedures could cause erectile dysfunction — the inability to maintain an erection firm enough to have sex. This is generally less of a risk with laser surgery compared 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 may grow back over time. This is not the case with enucleation. Men who have HoLEP generally don't require re-treatment, because the entire part of the prostate that can block urine flow is removed.
How you prepare
Follow your doctor's instructions on what to do before your treatment. Here are some issues to discuss with your doctor:
- Your medications. Tell your doctor about any prescription, over-the-counter or supplements you take. This is especially important if you take blood-thinning medications, such as warfarin (Coumadin) or clopidogrel (Plavix), and nonprescription pain relievers such as aspirin, ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others). Your surgeon may ask you to stop taking medications that increase your risk of bleeding several days prior to the surgery.
- Fasting before your procedure. Your doctor will likely tell you not to eat or drink anything after midnight the night before the procedure. On the morning of your procedure, take only the medications your doctor tells you to with a small sip of water.
- Arrangements after the procedure. Ask your doctor how long to expect to be in the hospital. You won't be able to drive yourself home after the procedure that day or generally if you have a catheter in the bladder.
- Activity restrictions. You may not be able to work or do strenuous activity for about two weeks after surgery, but depending on the type of laser procedure you have, you may need more or less recovery time. Ask your doctor how much time you may need.
What you can expect
Laser surgery for an enlarged prostate can take from 30 minutes to a couple of hours depending on the size and anatomy of the prostate being treated.
Before the surgery begins, 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 during the procedure.
Laser surgery techniques for enlarged prostate are all done by inserting viewing scopes and instruments through the tip of the penis into the urethra. This makes surgery possible without making any cuts (incisions) on the outside of your body.
Exactly what you can expect during and after the procedure can vary somewhat 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. By accessing the prostate through your penis, your doctor won't need to make any cuts (incisions) on the outside of your body. The doctor will use the laser to destroy, vaporize or cut out the prostate tissue blocking urine flow. Depending on the procedure, your doctor may also use instruments to remove cut pieces of prostate tissue from the bladder.
After the procedure
After the procedure, you may have a urinary catheter in place because urine flow is blocked by swelling. If you're unable to urinate after the tube is removed, your doctor may replace the catheter for some time 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 again normally.
You may also notice:
- Blood in your urine. You may see blood for a few days to weeks after the procedure. But if the blood in your urine is thick like ketchup, bleeding appears to be worsening or if blood clots block your urine flow, call your doctor.
- Irritating urinary symptoms. You may feel an urgent or frequent need to urinate, or you may have to get up more often during the night to urinate. Generally most men experience burning, especially at the tip of their penis, 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. This 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.
Follow your doctor's instructions about any specific restrictions or steps you need to take after the procedure. These may include:
- Take it easy. Don't do any strenuous activity, such as heavy lifting, until your doctor says it's OK. This can be up to two weeks after HoLEP, but as short as a few days with procedures such as PVP.
- Hold off on sex. Don't have sex until your doctor says it's OK. For most men, this is a week or two after the procedure. Having an orgasm (ejaculating) too soon may cause pain and bleeding.
- Watch for blood in your urine. You may see blood for a few days to weeks after the procedure. But if the blood in your urine is thick, the bleeding appears to be worsening or if a blood clot block your urine flow, call your doctor.
- Take medication as prescribed. If your doctor prescribed antibiotics, make sure to take the full course of exactly as your doctor says.
Prostate laser surgery improves urinary flow in most men. Often, results are long lasting. In some cases, especially ablation techniques, the laser surgery doesn't remove all of the prostate tissue blocking urine flow or the tissue grows back, and further treatment is needed. If you notice any worsening urinary symptoms, make an appointment to see your doctor.
- Management of benign prostatic hyperplasia (BPH). American Urological Association. http://www.auanet.org/education/clinical-practice-guidelines.cfm. Accessed April 16, 2013.
- Gravas S, et al. Critical review of lasers in benign prostatic hyperplasia (BPH). BJU International. 2011;107:1030.
- Wein AJ, et al. Campbell-Walsh Urology. 10th ed. Philadelphia, Pa.: Saunders Elsevier; 2012. http://www.mdconsult.com/das/book/body/208746819-6/0/1445/0.html. Accessed April 16, 2013.
- Lee J, et al. Advances in laser technology in urology. Urology Clinics of North America. 2009;36:189.
- Rieken M, et al. Complications of laser prostatectomy: A review of recent data. World Journal of Urology. 2010;28:53.
- Ahyai SA, et al. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. European Urology. 2010;58:384.
- Gnessin E, et al. An update on holmium laser enucleation of the prostate and why it has stood the test of time. Current Opinion in Urology. 2011;21:31.
- Prostate enlargement: Benign prostatic hyperplasia. National Institute of Diabetes and Digestive and Kidney Diseases. http://kidney.niddk.nih.gov/kudiseases/pubs/prostateenlargement. Accessed April 16, 2013.
- McVary KT, et al. Update on AUA Guideline on the Management of Benign Prostatic Hyperplasia. Journal of Urology. 2011;185:1793.
- Cunningham GR, et al. Surgical and other invasive therapies of benign prostatic hyperplasia. http://www.uptodate.com/home. Accessed April 16, 2013.
- Preparing for your operation and recover. American College of Surgeons. http://www.facs.org/patienteducation/surgery.html. Accessed April 16, 2013.
- Humphreys MR (expert opinion). Mayo Clinic, Phoenix, Ariz. May 22, 2013.