Prostate laser treatment

What is prostate laser treatment?

Prostate laser treatment uses a laser, guided through a thin viewing tube (a scope) passed up through your urethra (the tube that carries urine out of your body), to remove or destroy the part of your prostate that is blocking your flow of urine. Because the surgeon works through this natural passage, your skin is not cut at all.

What conditions does it treat?

This treatment addresses a condition called benign prostatic hyperplasia, or BPH for short, also known as an enlarged prostate. As men get older, the prostate can grow and press on the urethra, making it harder to pass urine.

This can cause:

• a weak or slow urine stream
• a flow that stops partway through and then restarts
• needing to pee more often, including at night
• a sudden urge to pee that is hard to hold
• feeling that your bladder has not fully emptied
• burning or discomfort when you pee.

It is worth knowing that this operation treats an enlarged prostate rather than prostate cancer. Surgeons do not remove your whole prostate gland during this procedure. If a blockage happens to be caused by prostate cancer, laser treatment can still ease that blockage, though it will not treat the cancer itself.

What are the benefits of having prostate laser treatment?

Because the whole operation is carried out through the urethra, you avoid the cuts, stitches and longer wound-healing time that come with open surgery. Many people are discharged within hours, or after a single overnight stay, rather than facing a longer hospital admission.

Other benefits include:

• a lower chance of heavy bleeding or needing a blood transfusion, compared with older surgical techniques
• a lower chance of needing a repeat operation later on
• some laser techniques can be used safely even if you take blood-thinning medication, such as aspirin, clopidogrel or warfarin
• some laser techniques work well whatever size your prostate is, including very large prostates.

Is there more than one type of laser treatment?

Surgeons can choose from a few different laser techniques, and the right one for you depends on your prostate, your symptoms and what equipment your surgical team is trained to use.

• Holmium laser enucleation (HoLEP). Your surgeon cuts the blocking tissue free in larger sections first (this cutting stage is called enucleation), then swaps to a second tool that breaks those sections up so they can be drawn out and sent for laboratory analysis. NICE (the National Institute for Health and Care Excellence) names this as the only laser-based option covered in its UK guidance for BPH, and it can be used no matter how large your prostate is. On average, surgeons clear away roughly half to two thirds of the whole gland during this procedure.
• GreenLight laser (photoselective vaporisation, or PVP). Rather than cutting tissue away, this laser vaporises the blocking tissue using concentrated heat. Because the tissue is vaporised rather than removed in pieces, it cannot be sent away for laboratory analysis afterwards.
• Holmium laser ablation (HoLAP). This technique destroys tissue with holmium laser energy in a similar way to GreenLight, but without the full cutting-away stage that HoLEP uses.
• Thulium laser prostatectomy. A newer laser type that can either cut away or vaporise tissue, giving your surgeon fine control and helping to reduce bleeding.

What happens before the operation?

Before your operation, your surgical team will ask about your medical history and carry out an examination, which may include checking your prostate directly. You can expect some or all of the following:

• a blood test that measures your PSA, or prostate-specific antigen, level
• a urine test (urinalysis)
• tests that measure the speed and volume of your urine flow, and how much urine is left in your bladder afterwards
• imaging, such as an ultrasound scan or a CT scan, to work out how large your prostate is
• a cystoscopy, where a thin camera looks inside your urethra, prostate and bladder
• a urodynamics test, which uses a catheter and pressure sensors to see how well your bladder is working.

Your surgical team will ask about any medication you take. Sources vary on how medication is managed before this operation: some describe stopping certain medicines, including blood thinners, for up to 10 days beforehand, while others describe your urologist prescribing blood-thinning medication or pain relief ahead of surgery.

Your own surgical team will confirm what you need to do with your specific medications. You will usually be asked not to eat or drink anything after midnight on the night before your operation.

What happens during the procedure?

This procedure is normally carried out under general anaesthetic, meaning you are fully asleep throughout. A spinal anaesthetic, numbing you from the waist down, is an option if general anaesthesia is not suitable. Antibiotics may also be given beforehand to lower your risk of infection.

1. Your surgeon passes a thin, telescope-like tool up through your urethra while you lie on your back; this tool is called a resectoscope, and it carries a small camera so the team can see your prostate on a screen.
2. A laser fibre is passed through this tool. Depending on the technique used, your surgeon either cuts away the blocking tissue (enucleation) or vaporises it directly, sealing small blood vessels as they go.
3. If tissue has been cut away rather than vaporised, your surgeon swaps the laser for a second instrument called a morcellator, which breaks the tissue into small pieces and suctions them out of your bladder. This tissue is then sent to a laboratory for analysis.
4. Once your surgeon is satisfied that the blockage has been cleared, the resectoscope is taken out and a catheter is put in place to drain your bladder.

How long the operation takes depends on which technique is used and how big your prostate is. HoLEP typically takes 1–3 hours, while GreenLight laser treatment more often takes 45–60 minutes.

What does recovery look like?

In hospital

Most people need only a short spell, often just a couple of hours, in a recovery bay after a general anaesthetic. Depending on the technique used and how you are healing, you might be discharged that same day, kept in overnight, or stay for 1–2 nights. Fluid is used to flush your catheter and clear any blood from your urine, and your catheter typically comes out the following day, or after a day or two, once your urine has cleared enough and you are able to pass urine again yourself.

At home

Sources describe a broadly similar recovery pattern, though the exact timings vary by technique and by surgical team. You can usually walk and, in time, drive again from the day after surgery. Guidance on returning to strenuous activity or heavy lifting typically falls somewhere between 2 and 4 weeks, while sport or straddle activities, such as cycling, are usually left until 4–6 weeks have passed.

Most people return to work within 1–2 weeks, though this can be longer if your job is physically demanding. Traces of blood when you pass urine are common for several weeks, and sometimes for a couple of months, as a normal part of healing.

Burning when you pee, and needing to pee more often or more urgently than usual, can also take weeks or months to settle, because your bladder needs time to adjust. Your team may suggest starting pelvic floor exercises, sometimes called Kegels, from your first full day home, to help with any leaking.

Most people notice their symptoms improve substantially within around 6 weeks, although your bladder can continue to improve for 6–9 months afterwards. You will usually be asked to come back for a check-up, which may include repeating your urine flow test and bladder scan, at around 12 weeks, with further reviews at 6 or 12 months if needed.

What are the risks and complications?

No operation is entirely free of risk, and here the risks vary somewhat depending on which laser technique is used.

• Waterworks problems. You may struggle to pass urine for a short spell afterwards, and some people need a catheter refitted for a while if this happens. Needing your catheter to stay in beyond a single day after surgery (sometimes called prolonged catheterisation) is described as a possible, though less common, complication.
• Infection. A urine infection is described as affecting around one in 20 people. Rarely, this can travel further to the testicles or need antibiotics given through a vein.
• Bleeding. Fewer than one in 100 people are thought to need a blood transfusion because of bleeding. Seeing some blood when you pass urine for a few weeks afterwards is part of normal healing, but heavy or persistent bleeding should be checked by your doctor or, if severe, at A&E.
• Dry or retrograde ejaculation. This is described as the most common lasting effect of this type of surgery, where semen passes back into the bladder instead of out through the penis during ejaculation. Depending on the technique, sources describe this affecting anywhere from around three quarters to nearly all men afterwards. It does not usually affect the pleasure of orgasm, though it can reduce fertility.
• Erectile dysfunction. Some sources describe erections as usually unaffected by this type of surgery, while others describe a risk of around one in 20, generally lower than with open prostate surgery.
• Urethral narrowing (stricture) or scar tissue. This can happen as the area heals, and may need a further procedure to correct it. Reported rates vary by technique, from around one in 20 to one in 50.
• Prostate regrowth. Because your surgeon leaves some prostate tissue behind rather than clearing the whole gland, it can grow back over time. Reported rates of needing further treatment for this vary by technique, from around one in seven over 10 years to around one in 20 over 5 years.
• Long-term incontinence. Described as affecting around one to two in 100 people, usually because of changes to the muscle that controls your bladder.
• Finding unexpected cancer. Because tissue removed during some laser techniques is sent for laboratory analysis, some people are found to have prostate cancer they did not know about. This is described as affecting between 5% and 15% of people having HoLEP. If cancer is found this way, having had laser treatment first will not get in the way of treating it.
• Anaesthetic risks. These include feeling tired, dizzy or weak afterwards, and rare risks such as blood clots or chest infection. In that first day, it is best to avoid driving, signing anything legally binding, or having an alcoholic drink.