ÃÛÌÒAPP

What does the procedure involve?

This operation involves the telescopic removal of obstructing prostate tissue using a laser and temporary insertion of a catheter which is removed the day after surgery in the majority of men

What are the alternatives to this procedure?

Observation/no treatment depending on symptoms, modifying fluid intake (caffeine reduction), medications, use of a catheter, conventional transurethral resection of the prostate or an open operation (with a skin incision in the tummy).

What should I expect before the procedure?

If you are taking Clopidogrel or any other blood-thinning medication on a regular basis, you must stop this before your admission. These drugs can cause increased bleeding after prostate surgery. Treatment can be re-started safely about 10 days after you get home. You will be advised by the Urology team well in advance of your operation.

You will usually be admitted on the day of your surgery. You will normally receive an appointment for pre assessment before your admission, to assess your general fitness and to perform some baseline blood and urine tests.

After admission, you will be seen by members of the medical team who will include the Consultant, your anaesthetist and your nurse. You will be asked not to eat or drink for 6 hours before surgery.

What happens during the procedure?

Either a full general anaesthetic (where you will be asleep throughout the procedure) or a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you. The operation, on average, takes 45-120 minutes, depending on the size of your prostate.

You will usually be given an injectable antibiotic before the procedure after checking for any drug allergies.

The laser is used to separate the obstructing prostate tissue from its surrounding capsule and to push it in large chunks into the bladder. An instrument is then used through the telescope to remove the prostate tissue from the bladder. A catheter is normally left to drain the bladder at the end of the procedure.

What happens immediately after the procedure?

There is always some bleeding from the prostate area after the operation. The urine is usually clear of blood after 24 hours, although it is quite common to see some blood in the urine, often intermittently, for even up to 6 weeks after surgery. This is not a concern surgically, and although blood in the urine may seem alarming to some people it is usually only a small amount of blood that is lost. It is very unusual to require a blood transfusion after laser surgery.

It is useful to drink more fluid than normal in the first 24 hours after the operation because this helps the urine clear of any blood more quickly. Sometimes, fluid is flushed through the catheter to clear the urine of blood. Many men are surprised at how comfortable they are after laser prostate surgery. Apart from some minor discomfort from the catheter irritating the penis and bladder, it is usual not to have any pain as such.

You will be able to eat and drink on the same day as the operation when you feel able to.

The catheter is generally removed the morning after surgery. At first, it may be painful to pass your urine and it may come more frequently than normal. Any initial discomfort can be relieved by tablets or injections and the frequency usually improves within a few days.

Some of your symptoms, especially frequency, urgency and getting up at night to pass urine, may not improve for several months because these are often due to bladder over activity (which takes time to resolve after prostate surgery) rather than prostate blockage.

Since a large portion of prostate tissue is removing with the laser technique (which means you will have excellent relief of prostate blockage and have a very low risk of ever needing a repeat prostate operation), there may be some temporary loss of urinary control until your pelvic floor muscles strengthen and recover. This is why pelvic floor exercises are taught prior to surgery. If you do these exercises as advised, the risk or urinary incontinence after surgery is very low and if it does occur it normally resolves completely within a few months (often within days).

Any incontinence is normally managed by wearing a pad inside the underpants. The need to use pads beyond 3 months occurs in less than 2% of men. Let your nurse know if you are unable to pass urine and feel as if your bladder is full after the catheter is removed.

Some patients, particularly those with small prostate glands, are unable to pass urine at all after the operation due to temporary swelling of the prostate area. If this should happen, we normally pass a catheter again to allow the swelling to resolve and the bladder to regain its function. Usually, patients who require re-catheterisation go home with a catheter in place and then return within a week for a second catheter removal which is successful in almost all cases.

The average hospital stay is 1-2 days.

What should I expect when I get home?

Most patients feel tired and below par for a week or two because this is major surgery. You may notice that you pass very small flecks of tissue in the urine at times within the first month as the prostate area heals. This does not usually interfere with the urinary stream or cause discomfort.

What else should I look out for?

If you experience increasing frequency, burning or difficulty in passing urine or worrying bleeding, please contact your doctor.

About 1 man in 5 experiences bleeding some 10-14 days after getting home; this is due to scabs separating from the cavity of the prostate. Increasing your fluid intake should help stop this bleeding within 24 hours but, if it does not, you should contact your urologist or your GP who may prescribe some antibiotics for you.

In the unlikely event of severe bleeding, passage of clots or sudden difficulty in passing urine, you should contact your GP immediately since it may be necessary for you to be re-admitted to hospital.

Are there any other important points?

Removal of your prostate should not adversely affect your ability to have an erection provided you are getting normal erections before the surgery. It is very common not to be able to ejaculate any semen at the point of orgasm after prostate surgery. This is because after surgery it is much easier for the semen to travel back into the bladder than down and out through the penis. This is not an uncomfortable or harmful consequence of surgery and most men say the experience of orgasm remains a pleasurable sensation. This is only a major issue if you intend fathering children in future. Sexual activity can be resumed as soon as you are comfortable, usually after 3-4 weeks.

It is often helpful to recommence pelvic floor exercises as soon as possible after the operation since this can improve your control when you get home. The symptoms of an overactive bladder may take 3 months to resolve whereas the flow is improved almost immediately.

The results of any tissue removed will be available after 14 – 21 days and you and your GP will usually be informed of the results by letter. If any results are best discussed with you in person, an appointment will be made for you to be seen in the clinic soon after the results become available.

You will be reviewed in the outpatient clinic and several tests repeated (including a flow rate, bladder scan & symptom score) to help assess the effects of the surgery. This is usually 3 months after the surgery to allow time for your waterworks to settle into a new pattern.

Most patients require a recovery period of 1-2 weeks at home before they feel ready for work. We recommend 2 weeks rest before resuming any job, especially if it is physically strenuous and you should avoid any heavy lifting during this time. You should not drive until you feel fully recovered; 1 week is the minimum period that most patients require before resuming driving.

Are there any side-effects of the operation?

Common side-effects (greater than 1 in 10)

• Temporary mild burning, bleeding and frequency of urination after the procedure
• No semen is produced during an orgasm in approximately 75% if the prostate is fully enucleated
• Treatment may not relieve all the urinary symptoms, but if this is the case a medication can sometimes help if required
• Infection of the bladder, testicle or kidney requiring antibiotics (approx 10-15%)
• Failure to pass urine immediately after surgery requiring placement of a new catheter which is then removed (almost always successfully) within a week (10-15%)

Occasional side-effects (between 1 in 10 and 1 in 50)

• Loss of complete urinary control (incontinence) which normally resolves within 6 weeks (less than 10%); this can usually be improved with pelvic floor exercises
• Weaker or no erections. 2 recent studies have shown no significant difference in ability to have an erection in men before and after HoLEP surgery but there is still a small risk (probably less than 5%) of a decreased ability to have an erection. Erections in some men actually improve after surgery
• Injury to the urethra causing delayed scar formation requiring further minor surgery (5%)
• Finding unsuspected cancer in the removed tissue which may need further treatment (5%)

Rare side-effects (less than 1 in 50)

• Need to repeat treatment later due to re-obstruction from prostate regrowth (approx 1% in the first 7 years after surgery· Self-catheterisation or permanent catheter to empty bladder if the bladder is weak (1%)
• Persistent loss of urinary control which may require a further operation (less than 1%)
• Retained tissue fragments floating in the bladder which may require a second telescopic procedure for their removal (less than 1%)
• Very rarely, perforation of the bladder requiring a temporary urinary catheter or open surgical repair (less than 0.5%)
• Bleeding requiring return to theatre and/or blood transfusion (less than 0.5%)