My HOLEP Experience — Holmium Laser Enucleation

[congecal2]

HOLEP = Holmium Laser Enucleation of the Prostate

Chronic prostatitis for 25 years. BPH for past 10 years or so. Both getting worse with time. Prostate was 76cc based on 3T MRI done in 6/2019. Prostatitis symptoms were constant burning in pelvic and genital region and with frequent urination (24/7). I woke up with burning pain at least 3 times a night. Also frequently peed blood. CAT scans and cystoscopies never indicated any obvious abnormalities.

Have been on antibiotics on and off for 25 years. Typically on antibiotics for 3 weeks minimum at a time. In recent years I have one to 2 flareups a year. Have been on antibiotics as long as 8 weeks at a time. Antibiotics take the edge off of the extreme pain when I get a flareup, but they don't eliminate the pain and frequency. After a course of AB's I revert back to my baseline level of moderate pain and frequent urination.

Antibiotics cause significant stomach upset and abnormal bowel movements. It takes up to 6 months after each round of AB's for my stomach to get back to normal again.

Ejaculation causes a significant flareup in pain and frequency that lasts 1-2 days. I take NSAIDS for this. No AB's.

I have tried almost all of the various treatments mentioned on this forum over the years. prostate massage, pelvic floor massage, supplements of all kinds, meditation, etc. Nothing helped much and the symptoms were becoming more and more debilitating with time. Of the things I tried, going on a low oxalate diet probably helped the most. Even though calcium oxalate stones were never detected in my body, there is a theory that some people might form calcium oxalate microcrystals that will irritate the urinary tract lining. Again, the benefit of this was still very limited.

No doctor every recommended surgery and many testimonials of people with chronic prostatitis who had TURP done said it only made things worse. In addition, I was very opposed to the idea of surgery.

I finally found a HOLEP doctor in Long Island, NY who has been doing Holep for 9 years who was the first to say that he had success treating prostatitis patients and actually recommended surgery. He said he no longer does Turp or Green light and felt confident that both of those procedures would make things worse for a prostatitis patient because they leave behind a lot of prostate tissue and cause a lot of scarring.

I had Holep on Jan 14, 2020 in an outpatient clinic. I wanted spinal anesthesia but due to a miscommunication I ended up having general anesthesia. General anesthesia has been linked to increased risk for dementia in the elderly. I am 65. I went home the same day with a catheter which was excruciatingly painful due to prostatitis.

Dr said a normal BPH patient without prostatitis would not have had so much pain. I also had a lot of bleeding. Catheter was removed the next morning in doctor's office. Continued to pee blood for about 2 weeks. Never experienced any clots coming out.

The burning and frequency improved over 3 months. At about 3 months the rate of improvement slowed down considerably. Now at 5 months I am definitely much better off than before surgery but I still have mild lingering burning and frequency. Dr said I could continue to see gradual improvement over many more months because the bladder itself needs to heal. My stream is also back to what it was in my youth. I had no incontinence.

I have had to go on antibiotics for a flareup every year for the past 20 years or so in the spring (probably because of pollen allergies that increase inflammation). This year it did not happen.

Dr said that he had a hard time removing the prostate adenoma because of the presence of extensive scar tissue due to repeated infections over the years. The scar tissue made it difficult to peal away the adenoma from the inside wall of the prostate capsule. Normally he said it peals away easily. In the end he persisted and removed even more than he normally would for BPH. He also reamed out the ejaculatory ducts because they tend to be sources of problems for prostatitis. He removed about 90% of the prostate in my case as opposed to about 80% in the normal BPH case.

Biopsy revealed no cancer but extensive inflammation.

I have retrograde ejaculation which is well worth it.

My main lingering complaint is increased burning and frequency after ejaculation. It is much less than before the procedure but it is still significant. Dr said if it is still there at 6 months he will order a CAT scan to see if ejaculatory ducts are obstructed in some way.

I suppose there might still be lingering pelvic floor dysfunction.

I need to stress, however, how much better I feel overall. For example, sitting for prolonged periods, rigorous exercise including strength training, crunches and other exercises that stress the pelvic floor do not cause an increase in symptoms like they did before. I could go much longer without having to pee. In addition, if I no longer end up having to take antibiotics I could live with the post ejaculatory pain even if it doesn't improve with time.

I just wish a doctor had recommended this procedure years ago. The idea of suffering with an inflamed, infected prostate and taking so many toxic antibiotics for so many years is mind boggling. Knowing what I know now I would have done a simple prostatectomy years ago if Holep wasn't available.

Clearly many have gotten relief through the various non-surgical modalities discussed in this forum. However, after my experience I think that one should seriously consider HOLEP by an experienced HOLEP surgeon if they have not gotten relief after a reasonable amount of time trying the non-surgical treatments. If extensive scar tissue is present as was the case for me, it is hard to imagine how something other than removal of the tissue could resolve the problem. There might actually be a way to test for the presence of extensive scar tissue before undergoing the procedure.

I am still on a low oxalate diet because I do believe that I have an issue there.

[webslave]

You mention "infection" and "infected" several times. What bacterium did your tests show, and how many tests showed the same bacterium?

[congecal2]

Tests never detected bacterium. Based on this I can never know for sure that the source of the problem was infection. I understand that antibiotics can reduce symptoms through an anti-inflammatory mechanism. The only thing that can be said for sure was that there was excessive inflammation (biopsy) and excessive scar tissue formation (found during procedure). I also should mention that unprotected sex with my wife would always lead to a major flare-up requiring antibiotics to cut the edge off the pain. Protected sex would lead to a temporary flare-up that would dissipate after a day or so.

[congecal2]

Let me also add that my wife also never tested positive for bacterium.

[webslave]

Well, you're 65 with BPH, so a good part of this was down to that condition. In my opinion you never had any infection and the difference between post-coital pain with or without condoms was neurological, having to do with degree of sensation.

[congecal2]

Actually, the BPH didn't start till I was around 60 while I have been experiencing severe debilitating chronic prostatitis symptoms since age 40 when my stream was perfectly fine. So I can't comment on the infection part, but this clearly was not originally caused by BPH. Also flareup without condoms does not go away even after several weeks and eventually leads to chills and slight fever which does not resolve until I eventually go on antibiotics for weeks at a time. I am very familiar with the debate between infection versus pelvic floor dysfunction. My personal opinion is that both factors are at play and that they feed on each other. Its possible that dysfunction somehow allows a simple infection to trigger inflammation along with the muscle tension itself which in turn may cause scar tissue, etc. Regardless of how the scar tissue got into the prostate, either by pelvic floor tension or infection or a combination of both, once its there its not clear that it can somehow be cleared out non-invasively. Perhaps if it is caught early enough and the scar tissue is only slight then non-invasive treatments may work. All of this is pure conjecture.

[webslave]

1. Removing an adenoma has nothing to do with CPPS, and surgery like this will not improve CPPS, only BPH. I've seen enough cases described to know I'm right about that.
2. If you had true bacterial prostatitis in the past, with chills and fever, a bug would have been isolated. You say one wasn't, so no, you did not have chronic bacterial prostatitis.
3. If you had your prostate re-infected by your wife every time you had unprotected sex, that would be such an unusual case that you'd be a world first and deserve to be written up in the literature.
4. "Scar tissue" is not a finding I have ever heard associated with CP/CPPS. You either have some other condition of the prostate or your doctor was exaggerating.

[jayz389]

Congecal2 I’m in a similar situation and considering Holep. My worst symptom is the voiding issue, incomplete emptying etc. I’ve also had scar tissue identified on MRI and inflammation seen on cysto. I’d like to talk further with you if possible. Please email me at [email protected] if you can. Thanks!!

[altair]

Also considering HOLEP for prostate inflammation and narrowing of the prostatic urethra. Can you share which doctor you saw? Please email me at [email protected]

[jayz389]

I am one of the rare ones but I feel obligated to come back here and post this now. My life for the last 15 months or so has been completely different. I'm someone where something actually finally did work for me. I had tried it all, spent thousands of dollars, pelvic physical therapy, every medication you could think of, flying out to California for intra-prostatic injections, and much much more. Some things worked a little but it all was temporary. I'm also fairly young, 33, but have had CPPS since I was 22 after after an episode of acute prostatitis in 2011. I finessed a local Holep surgeon here in Nashville TN into doing the Holep on me in July of 2021. She made me sign a bunch of waivers because of my age but knew my history and everything I tried so was willing to give it a shot since it was essentially my last resort. For what it's worth, my cysto was bad. Lots of inflammation and lateral lobes touching even with a small overall prostate. Within two weeks my symptoms were better, at a month I was essentially healed. Things have not changed and I've only improved. I'm honestly shocked thinking about it, that something actually finally worked. Thank God! I don't ever think about this stuff anymore after all the years of it ruling over my life. I've started my own business that's doing well, life is just so much different in a good way and I almost take it for granted sometimes now. I do have retrograde ejaculation but it's been well worth giving that up with my life essentially changing completely. Actually, one weird side effect is I can essentially have never ending orgasms now, it's very strange but good don't get me wrong. I joke with my wife about signing up for a study about this lol because it definitely was not like this when I was ejaculating normally before Holep. Anyway, I know this isn't the answer for everyone but for me it totally changed my and my family's life. Hope this helps give someone hope because I know what it was like feeling hopeless and honestly suicidal at times. Hang in there. If you're at the end of your rope, give it a shot because if you're were like me, there was nothing to lose as bad as my quality of life was. God bless!

[webslave]

I'm glad to see you were helped. Urethral obstruction and urinary reflux into the prostatic ducts may have been a major factor in your case. Were you ever put on a long course of alpha blockers?

A warning about HOLEP:

HoLEP is a minimally invasive procedure for lower urinary tract symptoms (LUTS) suggestive of BPH. Compared with transurethral resection of prostate (TURP), HoLEP is associated with a lower rate of perioperative complications and a shorter urethral indwelling catheter duration. However, HoLEP does carry a risk of postoperative complications, including urethral stricture, incontinence, erectile dysfunction (ED), retrograde ejaculation, and bladder neck contraction. The reported incidence of urethral stricture after HoLEP is 1.2 – 7.3%. However, the true incidence of urethral stricture is probably greater than the reported rates, due to variations in how and when the diagnosis is made.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6877364/