Expert highlights advancements in HoLEP for benign prostatic hyperplasia

In this interview, Smita De, MD, PhD, discusses the introduction of holmium laser enucleation of the prostate (HoLEP) and recent advances with the procedure that have improved the management of benign prostatic hyperplasia (BPH). De is an endourologist at Cleveland Clinic in Ohio.

Smita De, MD, PhD

Could you describe the introduction of HoLEP and its impact on patient care for BPH?

HoLEP stands for holmium laser enucleation of the prostate, and it is one of the many offerings for surgical management of BPH. It is recommended by the American Urological Association (AUA) for any size of prostate. One of the great things about HoLEP is how versatile it is. It can be used not only for any size of prostate, but for patients who may require a redo surgery, patients who may have issues with bleeding, or have weak bladders. It's a very effective procedure, and it is also very durable. Very few patients require repeated surgeries over their lifetime after they have had a HoLEP procedure.

One of the reasons HoLEP has been a little bit slow to be adopted in the United States is because of the equipment that's needed. A lot of people perceive that specialized equipment is needed, such as a high-power holmium laser. Although that's nice to have, what we're finding is that you can really use any energy source that you want to do prostate enucleation, and you can get very similar outcomes. A lower power holmium laser, one of the newer thulium fiber lasers, or even using some of the old school equipment like bipolar electrodes, those can all be used for prostate enucleation, and you still get those same durable outcomes and be able to operate on patients with any size prostate.

What are some recent advances with HoLEP that have improved care for patients with BPH?

In terms of recent advances with HoLEP, one of the things that made a difference, at least in my practice, was one of the newer pulse modulated holmium lasers. This is a more specialized holmium laser that has been shown, at least in some studies, to have improved hemostasis. That has allowed me to change my practice to essentially an outpatient surgery. The majority of my patients–probably about 95%–end up going home on the same day of their surgery, where previously I used to admit everybody overnight for CBI [continuous bladder irrigation]. I no longer need to do that. It has really changed my practice and is allowing me to do more cases within a day as well. Especially during COVID, it was great not having to admit patients, being able to do their procedure [and] get them out without using any hospital resources for overnight admission.

Another thing that has been great for HoLEP is having services where if you are unable to purchase equipment, so let's say a high-power laser, or possibly the specialized scopes or morcellators that are required to do a HoLEP or prostate enucleation, there are now services where you can rent this type of equipment on a per-case basis. For some people, that's allowing them to provide the service to patients without the hospital having to make a large capital purchase.

Is there anything else that you’d like to add?

I think one of the best things that's come up over the last couple of years is the development of much better simulators for training people in HoLEP. Back when I went through training, there were really no good trainer boxes, simulators, anything like that. Again, one of the big criticisms for HoLEP and why it hasn't really been adopted in the US very much up to this point, is that there was a very steep learning curve, and people just simply weren't able to put in the time and the number of cases to get to the point where they felt comfortable and were efficient. In the past couple of years, there have been at least 2 sets of great tissue simulators that have come out. I think they're really providing an opportunity for learning HoLEP.

There are [also] quite a few courses that have been popping up, [such as] ones that are put out by our various societies like the AUA or the Endourological Society. There are ones that are being put on by universities all over the country, [or] ones that are being sponsored by companies. I think there's actually a lot more opportunity to learn, and those of us who are in practice are also very excited to proctor and help mentor people, because we all really believe in HoLEP, or prostate enucleation. This combination of having the simulators along with a pretty good group of people who are willing to train is going to be great for promoting the growth of HoLEP in the US and abroad as well.