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Asian Healthcare Specialist
Asian Healthcare Specialist

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+65‎ 6334‎ 1486
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HOLEP Surgery in Singapore

An enlarged prostate can impact quality of life, causing frequent nighttime urination, weak urine flow, and the feeling of incomplete bladder emptying. For men experiencing symptoms that haven’t responded to medication, surgical options may be considered. Holmium Laser Enucleation of the Prostate (HOLEP) is a minimally invasive approach to treating benign prostatic hyperplasia (BPH) that may help reduce urinary symptoms. This treatment uses laser technology to remove excess prostate tissue whilst preserving surrounding structures, and aims to help improve urinary function. Individual results and timelines may vary.

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Dr. Nor Azhari Bin Mohd Zam

MBBS (NUS)|MRCS (Edin.)|MMed Surgery (NUS)|FAMS (Urology)

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Photo 1 HOLEP Surgery in Singapore
Suitability Techniques Process Recovery Benefits Risks Cost FAQ Conclusion
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Suitability
Techniques
Process
Recovery
Benefits
Risks
Cost
FAQ
Conclusion

What is HOLEP Surgery?

HOLEP surgery is a minimally invasive endoscopic procedure that uses a holmium laser to remove enlarged prostate tissue blocking the urethra. The procedure involves enucleating (removing whole lobes of) the enlarged prostate tissue from its capsule, similar to peeling an orange from its skin. HOLEP allows the removal of obstructing tissue even in huge prostate glands.

The holmium laser delivers energy to separate the enlarged prostate tissue from the capsule without cutting through it. The removed tissue is then morcellated (cut into small pieces) within the bladder and flushed out. This technique aims to preserve the prostate capsule and surrounding structures, including nerves responsible for continence and sexual function. The procedure seeks to treat benign prostatic hyperplasia by creating a channel for urine flow.

HOLEP may help address lower urinary tract symptoms associated with BPH, including frequent urination, urgency, a weak stream, straining, and incomplete emptying. The procedure aims to provide results with potential benefits, including reduced blood loss, shorter catheterisation time, and recovery period compared to some traditional approaches. The removed tissue can be examined pathologically to rule out prostate cancer, providing additional diagnostic value.

This treatment is administered as part of a comprehensive plan supervised by a healthcare professional.

Who is a Suitable Candidate?

Potential Candidates

Potential Candidates

  • Men with moderate to severe BPH symptoms affecting quality of life
  • Patients whose symptoms persist despite medical therapy with alpha-blockers or 5-alpha reductase inhibitors
  • Individuals with prostates of any size, including large prostates
  • Men experiencing recurrent urinary retention requiring catheterisation
  • Patients with bladder stones secondary to BPH
  • Those with recurrent urinary tract infections due to incomplete bladder emptying
  • Men considering a surgical treatment option
  • Patients who have not responded well to or experienced side effects from BPH medications
  • Individuals with elevated post-void residual urine volumes
Contraindications

Contraindications

  • Active urinary tract infection requiring treatment before surgery
  • Untreated bladder cancer or suspected prostate cancer requiring further evaluation
  • Severe bleeding disorders or inability to stop anticoagulation medications
  • Neurogenic bladder conditions unrelated to BPH
  • Urethral strictures requiring treatment before HOLEP
  • Severe cardiopulmonary conditions make anaesthesia high-risk
  • Previous pelvic radiation affecting tissue healing

A thorough urological assessment is essential. Your urologist may evaluate your specific anatomy, symptom severity, overall health status, and treatment goals to determine whether HOLEP surgery is appropriate for your situation.

Treatment Techniques & Approaches

  • Holmium Laser Enucleation Technique

    The holmium laser operates at a wavelength of 2,140 nanometres, providing both blood clotting properties and tissue-cutting capabilities. During enucleation, the urologist identifies the surgical capsule plane and uses the laser to separate enlarged tissue from the capsule. The procedure follows natural tissue planes, allowing removal of obstructing tissue while preserving the peripheral zone. This technique aims to minimise bleeding and provide visualisation throughout the procedure.

  • Morcellation Process

    After enucleation, the freed prostatic lobes are pushed into the bladder for morcellation. A morcellator device with rotating blades cuts the tissue into small fragments that can be evacuated through the scope. Modern morcellators include safety features to protect the bladder wall during tissue removal. The duration of the morcellation process varies depending on the amount of tissue removed.

  • En-bloc vs Multi-lobe Technique

    Urologists may employ different enucleation strategies based on prostate anatomy. The en bloc technique removes the enlarged tissue as one piece, while the two-lobe or three-lobe technique divides the tissue for easier manipulation. The choice depends on prostate size, anatomy, and the urologist’s preference. Both approaches aim to achieve tissue removal.

  • Technology & Equipment Used

    HOLEP requires equipment, including a holmium laser system, a continuous-flow resectoscope, a tissue morcellator, and laser fibres. The procedure uses saline irrigation for visualisation and cooling. Video monitoring systems provide magnified views of the surgical field, enabling tissue dissection.

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The Treatment Process

Pre-Treatment Preparation

Before HOLEP surgery, you’ll undergo a comprehensive evaluation, including urine tests, blood work, and prostate-specific antigen (PSA) testing. Your urologist may perform a cystoscopy to assess your urethra and bladder. Uroflowmetry and post-void residual measurements help document baseline function. You’ll need to stop blood-thinning medications as directed by your healthcare professional.

Preoperative antibiotics may be prescribed to prevent infection. You’ll fast from midnight before morning procedures. Arrange transportation home and support for the first few days post-surgery. Some patients may benefit from pelvic floor exercises started before surgery to support continence recovery.

During the Procedure

HOLEP surgery duration varies depending on prostate size. After spinal or general anaesthesia administration, you’re positioned for surgical access. The urologist inserts the resectoscope through the urethra to reach the prostate. Using the holmium laser, the urologist carefully enucleates the enlarged tissue following the capsular plane.

The laser energy simultaneously cuts and coagulates tissue, aiming to minimise bleeding. Once enucleation is complete, the tissue is repositioned into the bladder for morcellation. Throughout the procedure, continuous irrigation maintains clear visualisation. After tissue removal, the urologist inspects the prostatic fossa for bleeding and assesses the channel for patency.

Immediate Post-Treatment

Following surgery, you’ll recover in the post-anaesthesia care unit with a urinary catheter in place for continuous bladder drainage. The catheter irrigation may continue to clear blood and small tissue fragments. Patients may experience mild discomfort, which can be managed with pain medication. You’ll be encouraged to walk soon after recovering from anaesthesia.

Hospital stay duration varies by individual case. Before discharge, nursing staff may need to assess adequate urine output and manageable discomfort. You’ll receive instructions on catheter care, activity restrictions, and warning signs to monitor. The catheter duration varies based on individual recovery.

Recovery & Aftercare

First 24-48 Hours

Immediately after HOLEP surgery, expect blood-tinged urine, which gradually clears. Drink plenty of water to flush the bladder and prevent clot formation. Mild burning during urination and urgency are regular after catheter removal. Avoid straining during bowel movements; stool softeners may be prescribed.

Pain is typically minimal and managed with standard painkillers. Some patients may experience temporary urinary frequency and urgency as the bladder adjusts. Walk regularly to prevent blood clots, but avoid strenuous activity. Monitor for signs of infection, including fever, severe pain, or cloudy urine.

First Week

During the first week, continue drinking adequate fluids daily to maintain clear urine. Gradually increase activity levels but avoid heavy lifting. Some patients may experience temporary stress incontinence, particularly with coughing or sneezing. Pelvic floor exercises may help support the recovery of continence.

Your urologist may schedule a follow-up appointment to assess healing and address concerns. Avoid driving until off narcotic pain medication. Sexual activity may be avoided as advised by your healthcare professional. Continue prescribed drugs, including antibiotics if prescribed. Small tissue fragments may pass in urine – this is normal.

Long-term Recovery

Healing occurs over several weeks to months. Continence recovery timelines vary by individual. Urinary symptoms may progressively improve as swelling resolves and the bladder adapts. Sexual function may return to baseline, though retrograde ejaculation can occur after HOLEP.

Return to normal activities, including exercise, needs to be discussed with your urologist. Long-term follow-up includes periodic assessment of urinary function and PSA monitoring. The procedure aims to provide sustained symptom improvement.

Dr Azhari provides post-procedure support to help with recovery.

Schedule your consultation to learn more about what to expect.

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Benefits of HOLEP Surgery

HOLEP surgery may help improve urinary flow rates and symptom scores. The procedure can treat prostates of various sizes and aims to remove tissue effectively, potentially reducing the need for future treatments compared to some other BPH procedures.

The minimally invasive approach may result in less blood loss than traditional surgery and potentially reduce the need for transfusions. Shorter catheterisation time and hospital stay may allow for faster return to normal activities. The procedure aims to preserve sexual function in patients whilst treating urinary symptoms.

Tissue removed during HOLEP can undergo pathological examination, which may provide cancer screening information. The procedure may reduce the need for long-term BPH medications and their associated side effects. Patients may experience improvements in quality of life, including symptom relief and improved bladder emptying.

Risks & Potential Complications

Common Side Effects

Temporary urinary urgency and frequency may occur during the initial recovery period. Mild stress incontinence may occur, particularly in older patients, but may improve with pelvic floor exercises. Retrograde ejaculation, where semen enters the bladder instead of exiting through the penis, can occur, but doesn’t affect orgasm sensation.

Blood in urine may be expected initially and may recur temporarily with increased activity. Temporary burning sensation during urination may resolve as tissues heal. Some patients may experience bladder spasms that can be treated with anticholinergic medications.

Rare Complications

Urinary tract infections may occur and can respond to antibiotic treatment. Bladder injury during morcellation is possible. Urethral strictures may develop, potentially requiring dilation or incision. Persistent incontinence may affect some patients.

Severe bleeding requiring transfusion is possible. Capsular perforation, while uncommon, may extend operative time but is unlikely to cause long-term issues. These risks may be minimised through meticulous surgical technique, appropriate patient selection, and experienced urological care.

Cost Considerations

HOLEP surgery costs vary based on hospital facility fees, the urologist’s experience, the type of anaesthesia, and the length of hospital stay. The comprehensive fee typically includes preoperative assessments, the surgical procedure, operating room costs, initial hospital recovery, and immediate post-operative care. Modern laser technology and equipment contribute to overall costs.

Additional considerations include pathology examination of removed tissue, post-operative medications, and follow-up consultations. While HOLEP may have higher upfront costs than some alternatives, the procedure aims to provide durable outcomes. The potential reduction in ongoing medication requirements may be factored into treatment decisions.

Professional surgical care provided by experienced urologists, using contemporary equipment, is a treatment option for urological health. During consultation, you’ll receive a detailed cost breakdown tailored to your specific needs and clinical requirements.

Frequently Asked Questions

How long does HOLEP surgery take to perform?

HOLEP surgery may take 60-120 minutes, depending on prostate size and anatomy. Larger prostates may require more time for complete enucleation and morcellation. The urologist’s experience can also influence operative time. Despite a longer duration than some alternatives, HOLEP’s complete tissue removal may justify the time investment. Patients spend an additional hour in recovery before returning to their hospital room.

When can I return to work after HOLEP surgery?

Patients with desk jobs may be able to return to work within 1-2 weeks after HOLEP surgery. Those with physically demanding occupations may need to wait 4-6 weeks before resuming heavy labour. Individual recovery varies based on age, overall health, and healing response. Your urologist can provide specific guidance based on your occupation and recovery progress. A gradual return to complete activities supports optimal healing.

Is HOLEP surgery painful?

HOLEP surgery may cause minimal pain compared to open prostate surgery. Patients may describe mild discomfort rather than significant pain, which can be managed with standard pain medications. Common sensations may include bladder spasms and burning during urination, which can improve over the first week. The minimally invasive nature means no external incisions or wounds. Patients may require only over-the-counter pain relievers after the first few days.

Will HOLEP affect my sexual function?

HOLEP surgery may preserve erectile function since nerve bundles responsible for erections remain untouched. Retrograde ejaculation may occur, meaning semen enters the bladder rather than exiting normally. This doesn’t affect orgasm sensation or pleasure but does impact fertility. Sexual activity can usually resume 3-4 weeks post-surgery. Discuss specific concerns about sexual function with your urologist during consultation.

How long do HOLEP results last?

HOLEP may provide durable, long-term results with sustained symptom improvement. The complete removal of obstructing tissue means retreatment rates are low. Unlike medications that require ongoing use, HOLEP aims to offer a long-term approach to BPH symptoms. While the peripheral prostate may continue to grow slowly, significant regrowth causing symptoms is uncommon. Regular follow-up helps monitor long-term prostate health.

Can HOLEP be performed on very large prostates?

HOLEP may be suitable for large prostates that may not be treatable with other minimally invasive techniques. The procedure can treat large prostates that would otherwise require open surgery. The enucleation technique allows systematic removal of obstructing tissue. Larger prostates may require longer operative times for complete treatment. This makes HOLEP a versatile option for various prostate volumes.

What happens to the removed prostate tissue?

The prostate tissue undergoes pathological examination to check for unexpected cancer or other abnormalities. The tissue is first morcellated into small fragments during surgery, then collected and sent to the laboratory. Pathology results may arrive within a week, providing valuable diagnostic information. This cancer screening benefit enhances the therapeutic procedure. Your urologist can discuss pathology findings during follow-up appointments.

How soon will I see improvement in my symptoms?

Initial improvement in urine flow may occur after catheter removal, though some temporary symptoms like urgency may persist. Patients may notice symptom improvement within 2-4 weeks as swelling resolves. The maximum benefit may occur within 3 months, when healing is complete and the bladder has adapted. Individual recovery timelines vary, but patients may experience substantial long-term symptom relief.

Conclusion

HOLEP surgery represents an effective treatment option for men with enlarged prostate symptoms that impact their quality of life. The procedure aims to remove obstructing tissue whilst preserving critical anatomical structures and can be suitable for prostates of various sizes. With its minimally invasive approach, HOLEP may help relieve BPH symptoms and improve urinary function.

Ready to Take the Next Step?

If you’re considering HOLEP surgery, Dr Azhari can help you understand if it’s a suitable option for your needs.

Book Your Consultation Today
Dr. Nor Azhari Bin Mohd Zam

Dr. Nor Azhari Bin Mohd Zam

MBBS (NUS)|MRCS (Edin.)|MMed Surgery (NUS)|FAMS (Urology)

With more than 15 years experience as a certified Urologist, Dr Nor Azhari specializes in treating a wide range of kidney, bladder and prostate conditions as well as disorders of the male reproductive organs.

He offers minimally invasive treatment options and provides same-day appointments for convenience.

  • Skilled urologist and kidney stone surgeon.
  • Director of Endourology (Urinary stone service) at Singapore General Hospital – 2016 to 2023.
  • Recognized with the College of Surgeons Gold Medal and Singapore Urological Association Book prize.
  • Minimally invasive treatment options available (non-invasive and endoscopic/key-hole techniques).
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