Benign prostatic hyperplasia (BPH) refers to the abnormal enlargement of the prostate gland in men. It commonly develops as men age. When the prostate enlarges, it can compress the urethra and interfere with normal urine flow, leading to various urinary symptoms such as weak urine stream, difficulty starting urination, or incomplete bladder emptying.
One of the surgical treatments used to manage benign prostatic hyperplasia is holmium laser enucleation of the prostate (HoLEP). This procedure uses a holmium laser to precisely remove the enlarged prostate tissue that is blocking the urethra. By eliminating the obstructive tissue, the surgery restores the normal urinary pathway and improves urine flow.
HoLEP is considered a minimally invasive procedure because it is performed through an endoscope inserted through the urethra rather than through an external incision. The laser simultaneously cuts and cauterizes tissue, which reduces bleeding during surgery. Because of this, recovery time is generally shorter and the risk of complications is relatively low. For example, the incidence of postoperative urinary incontinence is reported to be less than 1 percent. To better understand which patients benefit most from HoLEP surgery, several clinical cases can be examined.
The first example involves bladder dysfunction caused by long-standing obstruction. Patient A underwent cystoscopy, which revealed trabeculation inside the bladder. Trabeculation refers to the formation of thickened ridges within the bladder wall, which occurs when the bladder muscle must work harder over time to push urine through an obstructed urethra. As trabeculation becomes more severe, the bladder gradually loses its ability to contract effectively. To prevent further deterioration of bladder function, HoLEP surgery was performed. After surgery, the patient’s maximum urinary flow rate improved significantly to 25.3 mL per second.
The second case involved a patient with a large amount of post-void residual urine. Patient B voided approximately 295 mL of urine, but 142 mL remained in the bladder afterward. When more than 100 mL of urine remains after urination, it can increase the risk of complications such as recurrent cystitis or kidney function decline. HoLEP surgery was performed for this patient as well. After treatment, the maximum urinary flow rate increased to 33 mL per second, and the residual urine volume was almost completely eliminated.
The third case involved enlargement of the median lobe of the prostate. When the median lobe becomes significantly enlarged, it can protrude into the bladder and severely compress the urethra, leading to marked urinary obstruction. Patient C had only mild prostate enlargement, with a prostate volume of about 29.5 grams. However, the median lobe was protruding into the bladder, resulting in a very weak urine flow of only 6.5 mL per second. In cases with a prominent median lobe, procedures such as UroLift may not be effective. HoLEP surgery was therefore performed, and the patient’s maximum urinary flow rate improved to 24.3 mL per second.
These cases illustrate why HoLEP surgery can be highly effective for treating benign prostatic hyperplasia. Because the enlarged prostate tissue is completely removed, urinary symptoms often improve dramatically. The ability to cut and coagulate tissue simultaneously minimizes bleeding during surgery and can significantly reduce operative time compared with traditional surgical techniques. Since the obstructive tissue is removed rather than simply reduced, the risk of recurrence is also relatively low. In addition, HoLEP surgery is typically covered by national health insurance in Korea, making it a cost-effective treatment option.
Beyond the three examples discussed above, HoLEP can also be particularly beneficial for patients with elevated prostate-specific antigen (PSA) levels, narrowing of the bladder neck (the junction between the bladder and urethra), or cases in which the prostate protrudes into the urethra or bladder.
Choosing the appropriate treatment for benign prostatic hyperplasia should always be based on the patient’s individual condition and clinical needs. HoLEP surgery can be an excellent option for many patients. At our hospital, more than 150,000 accumulated clinical cases since 2002 have helped guide evidence-based treatment decisions so that each patient receives the most appropriate surgical approach only when necessary.
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