Why have prostate surgery with a Holmium laser?
The prostate is a gland that is used to form semen and over the years it grows in size and causes pathologies in 3 ways:
- Prostate cancer; it is the most frequent cancer in men.
- Benign prostatic hyperplasia, which is the benign growth and is not related to cancer. It is the most frequent non-oncological pathology suffered by men.
- Prostatitis: infections.
We are going to focus on benign prostatic hyperplasia. With this growth that the prostate suffers, what happens is that it prevents the urine from flowing out of the bladder, so that as it grows, it makes the urine stream thin and short, making it difficult to start urinating and then, as the bladder wall thickens because it has to handle high pressures in order to empty, it prevents the bladder from filling well, making it distensible. All this means that we have to urinate frequently and that our frequency of urination increases, both during the day and at night. This prevents us from having a good quality of life.
At first we start with medical treatment, but when this fails or when complications appear in the form of acute urinary retention and catheterization of bladder stones, bladder bleeding, repeated infections, impaired renal function, we resort to surgical intervention.
I will explain what we do with a very graphic simile so that it is well understood: prostate cancer develops in what would be the peel of an orange, in the peripheral part of this orange, and what grows over the years are the segments, so that as they grow it is what produces the obstruction. What we try to do is to remove these segments, to remove the adenomatous tissue so that the urine can flow out properly.
Historically, when the prostate weighed less than 60-80 grams, a classic resection was performed through the urethra, with an electric scalpel, and a channel was opened so that the patient could urinate better. When the prostate was larger than 60-80g, the prostatic capsule was opened and the adenoma was removed so that urine could flow properly through the prostate gland.
The best functional results are obtained with open surgery, because you remove all the adenomas in such a way as to avoid recurrences; however, you have to open the patient, there is a surgical wound, you have to leave a probe in place that will be in place for around 10-14 days, there is an average of 4 or 5 days of hospitalization, risks of bleeding, wound infection. In short, it has consequences that can be very negative for people.
This is the reason why lasers have arrived in Urology. With the new technologies, the aim was to open a larger working channel in the prostate through the urethra so that more urine could flow out. Thus came the green laser, which opens a larger passage channel, but leaves a lot of adenomatous tissue and in the end the experience, the scientific evidence, most of the studies say that you should not operate on prostates larger than 60-80 grams with green laser, because you leave a lot of adenomatous tissue, which grows back and you return to the same clinical situation you were in before the operation.
We always recommend Holmium laser surgery because what we do is that we mimic open surgery. We enter through the urethra, we go between the capsule and the adenoma, we go between that shell and those segments, we put the whole adenoma inside the bladder, then we crush it and without opening the patient we obtain exactly the same functional results as with open surgery, but with an average of 36 hours of catheterization, instead of the 10-14 days that it would take. We have an average admission time of also 36 hours, compared to those four or five days that are with open surgery. There is no incision, so there is less pain, less risk of wound infection and bleeding is minimized, so the Holmium laser allows us to obtain the same results with minimal complications.
Thus, the Holmium laser has revolutionized prostate surgery. We are pioneers since 2007 when we started doing it; we have performed more than 1300 cases, we have published it and we have contributed it to all the scientific meetings of the highest level of impact, not only nationally but also internationally. And today our team, which is a national and international pioneer in this type of technique, we are a reference training center for the companies that commercialize the laser and we have a training program and many professionals come, not only nationally but internationally, to train with us in this technique. So whoever has to undergo prostate surgery should always choose the Holmium laser because it is suitable for all prostate sizes, you can treat any stones you may have in the bladder at the same time, you have no problems with patients who are anticoagulated or anti-aggregate, you obtain the best functional results with the least possible consequences, with the least possible complications.
Why is it not convenient to have prostate surgery with green laser?
The prostate should not be operated with green laser because it is “prostate size dependent”, i.e. the larger the prostate the worse the functional results obtained with green laser. What is clear is that prostates larger than 60-80g should not be treated with this technique. There are professionals who say that they are capable but we must believe the scientific literature and assume that they are not treatable. In addition, what the green laser does is to open a channel in the prostate. It does not treat the entire adenoma and, finally, it is not capable of treating the stones that the patient may have in the bladder. So if you are going to have surgery and you can have a Holmium laser instead of a green laser, have Holmium because with Holmium you can treat all prostate sizes, you can treat the stones inside the bladder, you obtain the best functional results, much better than the green laser, with minimum complications and, in addition, it is a procedure in which there are no recurrences since the entire adenoma is removed.
When is prostate surgery necessary?
The prostate is operated on as a consequence of benign prostatic hyperplasia when we have a patient who, despite the fact that we are giving him medical treatment and healthy habits so that he has a better quality of urination life, we cannot get him to improve and that patient continues to have to urinate with a very weak stream, he has to wait for a toilet to go to urinate, getting up at night. So the patient reaches a point where he/she demands a solution and the solution to that obstruction is always surgical. Then there are five other clinical scenarios in which it is imperative to operate and there it is not negotiable:
- When a patient enters retention and has a catheter in place, the adenomatous tissue must be removed, otherwise it is impossible to urinate again without a catheter;
- When there are repeated infections
- When there are bladder lithiasis, stones in the bladder formed by obstruction.
- When we have bleeding of prostatic origin of this hyperplasia,
- When we have deterioration of renal function.
For all patients with surgical indications we always recommend nucleating with the Holmium laser, since we will be able to treat all prostate sizes with the best functional results and it should be the technique of choice. This is already being recognized by the European Urology guidelines.
What should we ask ourselves once we have decided to undergo surgery?
When a person undergoes prostate surgery for benign prostatic hyperplasia, it is because he has a secondary complication of his prostate, or because he has a urinary clinic that prevents him from having a good quality of life. What should be considered is the procedure that is going to allow him to have the best functional results, the technique that will unblock the most, with the least complications. So we should take into account the prostatic size, whether I have associated bladder stones or not, whether I have associated urethral strictures or not, and my age. Why put all this into a cocktail shaker? Because what we need is a surgical technique that can allow me to have the versatility to solve all these possible problems that may appear during surgery. The only surgical technique that is capable of resolving urethral stricture, any prostatic size, associated bladder stones and that works well for all ages of patients because it has been shown to minimize bleeding and is very safe, is Holmium laser nucleation. However, what I must tell you is that to be operated with a Holmium laser, with a nucleation of this type, it is necessary professionals who have a great experience since it is a complicated technique that requires a great amount of instruments.