Holmium Laser Enucleation of the Prostate (HoLEP): Platinum Standard for BPH Therapy?
Amy E. Krambeck, MD, professor of Urology, discusses holmium laser enucleation of the prostate (HoLEP) for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia (BPH). She describes how HoLEP compares to other surgical BPH treatments and how MOSES-enabled pulsed laser modulation (MoLEP) advances the procedure.
Featured Speaker:
Amy Krambeck, MD
Amy Krambeck, MD's completed medical school training at University of Missouri-Columbia School of Medicine there she received the Janet M. Glascow Award, which is awarded to any woman who graduates as valedictorian of their medical school class. Dr. Krambeck completed her urology residency at Mayo Clinic in Rochester, Minnesota in 2008. Transcription:
Holmium Laser Enucleation of the Prostate (HoLEP): Platinum Standard for BPH Therapy?
Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And I invite you to listen as we discuss holmium laser enucleation of the prostate or HoLEP for the treatment of lower urinary tract symptoms related to BPH. Joining me is Dr. Amy Krambeck. She's a professor of urology at Northwestern Medicine.
Dr. Krambeck, it's a pleasure to have you join us today. Tell us a little bit about your background and expertise in BPH and how you came to Northwestern Medicine.
Dr Amy Krambeck: Well, thank you so much for having me. I started my training at Mayo Clinic. I finished my residency there in Rochester, Minnesota in 2008. And then I did a year-long fellowship at Indiana to learn how to do HoLEP as well as complex treatment of stone disease. Then I went back on staff at Mayo Clinic in 2009 and I did the first HoLEP there. I worked at Mayo Clinic for seven years and then was recruited back to Indiana University to take over the training program. And this is the largest training program for HoLEP in the nation. I've been here for almost five years and then decided to make the change to Chicago since a large majority of my patients already come from the state of Illinois. It just seemed logical to go to them instead of having them come to me.
Melanie: Well, we welcome you here in Chicago, and so glad to have you and this unique expertise. So Dr. Krambeck as lasers have become a novel way to open wider channels, improve voiding dynamics, many different techniques have evolved, right? Tell us how this has changed the landscape of BPH symptom management and lower urinary tract symptoms. Please talk specifically about HoLEP as a surgical BPH treatment and what are the benefits?
Dr Amy Krambeck: Well, I may be biased, but I personally think that HoLEP is not the gold standard, but the platinum standard for BPH therapy. It has been more widely studied than any other surgical procedure for BPH. And there's been more randomized clinical control, trials, more meta-analyses, more case studies on HoLEP than any other surgery and outcomes are phenomenal.
Long-term data shows that the prostate, although it regrows throughout the course of your lifetime, it never gets big enough to re-obstruct again. So the retreatment rate after HoLEP is less than 1% with studies that go out to 18 years, which is almost unheard of. It's also exceptionally safe. It's one of the few treatments that you can do in the anticoagulated patient or the patients with bleeding disorders.
And there's no size limit for HoLEP. Any prostate is a candidate. There's no prostate that's too big or too small. So it's just a phenomenal therapy. Patients have been shown to have sustained relief of their symptoms and very short convalescent periods after the procedure.
Melanie: Isn't that interesting? So as long as you mentioned symptoms, is it true that men don't often seek treatment until their symptoms become quality-of-life-limiting? Tell us how you stratify symptom burden in your decision to use HoLEP and, while we're talking about utilization, why isn't it more popular or widely used among urologists?
Dr Amy Krambeck: Yes. To answer your first question, it is unusual that men do not seek treatment early. They tend to hide their symptoms for a very long time until it becomes a huge impact on their quality of life. I tend to stratify men into two categories. There's those that absolutely need surgery. They can't urinate. Their kidney function is damaged. They're having gross hematuria or they're having recurrent infections. Those men really have to have a surgical intervention. And then there's men that it's more of a quality of life issue. Like how many times are they getting up at night? Are they changing their daily activities to go to the bathroom? Are they having incontinence episodes? And those men also I tend to encourage them to seek surgical intervention too, especially if they've tried medication and failed.
The reason I feel that HoLEP is not more widely utilized is it takes a long time to learn how to do it and to do it well. So most people who do HoLEP have spent at least a year, if not longer, doing specialized training to learn how to do the surgical procedure. Once you master it, it’s very easy to replicate the good outcomes, but it takes about 50 to 100 cases to get to a point of minimal mastery to perform this procedure. So that's why it's not more widely utilized.
Melanie: Wow. So you just pretty much described maybe one of the disadvantages of the technique, but speak about the technique itself, Dr. Krambeck. And how does it compare to TURP?
Dr Amy Krambeck: With a TURP, you go in with a scope through the urethra and you shave out pieces of tissue or shave out pieces of prostate until you have an open enough channel for someone that you think could urinate. With HoLEP, it's completely different. You do go through the urethra with a scope, so it's a natural orifice surgery, but you're using the laser to cut like a knife. And you can actually peel a prostate, like you can peel an orange. So the knife cuts through to the capsule. And then you peel out all the adenoma like you're peeling off the rind of an orange and that's deposited into the bladder. And then you use a morcellator to chew up that tissue and remove it from the body.
So it's a phenomenal technique, phenomenal procedure. And there's really only one way to do it, just like there's only one way to peel an orange.
Melanie: Well, how does it also compare to MOSES enabled pulse laser modulation or MoLEP?
Dr Amy Krambeck: Yeah. So MoLEP is some phenomenal new technology that's currently on the market. And basically Lumenis has taken the holmium laser and modified the bubble formation so that you have better energy delivery to the capsule into the tissue. And that translates into a more efficient surgery. So it takes less time to do the procedure and it translates into less bleeding. So with the MOSES technology or what we call MoLEP, you're doing a HoLEP surgery, but you're using this new laser. And it results in being able to send the patients home the same day. You can take their catheters out the same day. You can safely treat people who are anticoagulated and there is no limit to how big of a prostate you can treat. So it's really advanced the procedure to the next level and made it exceptionally safe and efficient.
Melanie: Do you want to briefly please discuss your recent paper published in urology for us?
Dr Amy Krambeck: Yes. So in the most recent paper, we looked at the MOSES technology and compared it to standard holmium technology for HoLEP. And we found that when we use the MOSES technology or the MoLEP, the amount of time we spent trying to control bleeding was decreased, or enucleation time or the amount of time we were operating was also decreased. And we were more likely to be able to send the patients home the same day.
And that's just huge because if you look back 10 to 15 years, men with 100 to 200-gram prostates were spending, you know, several days in the hospital after an open suprapubic prostatectomy. Now, we're sending them home the same day and sometimes even without a catheter and no blood transfusions. It's really just taken a very complex clinical scenario and made it more safe and with minimal morbidity to the patient.
Melanie: So interesting. What an exciting time to be in your field, Dr. Krambeck. As we wrap up, is there anything else that you'd like providers to know about treating patients with BPH or when you feel it's important that they refer, and what you would like them to know as you join Northwestern medicine?
Dr Amy Krambeck: I like them to know that I'm very excited to be in Chicago and I'm here to help. So if you see a patient that has an exceptionally large prostate or who has failed prior BPH procedures, maybe they have an enlarged prostate, but an acontractile bladder or they're on complex anticoagulation, or have complex BPH and stone disease, please send them my way. These are the patients that do very well with the HoLEP surgery or the MoLEP surgery, and they can have an excellent outcome like everyone else.
Melanie: Thank you so much for joining us today and telling us about this fascinating new procedure. To refer your patient or for more information, please visit our website at NM.org/urology to get connected with one of our providers
That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts.
I'm Melanie Cole.
Holmium Laser Enucleation of the Prostate (HoLEP): Platinum Standard for BPH Therapy?
Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And I invite you to listen as we discuss holmium laser enucleation of the prostate or HoLEP for the treatment of lower urinary tract symptoms related to BPH. Joining me is Dr. Amy Krambeck. She's a professor of urology at Northwestern Medicine.
Dr. Krambeck, it's a pleasure to have you join us today. Tell us a little bit about your background and expertise in BPH and how you came to Northwestern Medicine.
Dr Amy Krambeck: Well, thank you so much for having me. I started my training at Mayo Clinic. I finished my residency there in Rochester, Minnesota in 2008. And then I did a year-long fellowship at Indiana to learn how to do HoLEP as well as complex treatment of stone disease. Then I went back on staff at Mayo Clinic in 2009 and I did the first HoLEP there. I worked at Mayo Clinic for seven years and then was recruited back to Indiana University to take over the training program. And this is the largest training program for HoLEP in the nation. I've been here for almost five years and then decided to make the change to Chicago since a large majority of my patients already come from the state of Illinois. It just seemed logical to go to them instead of having them come to me.
Melanie: Well, we welcome you here in Chicago, and so glad to have you and this unique expertise. So Dr. Krambeck as lasers have become a novel way to open wider channels, improve voiding dynamics, many different techniques have evolved, right? Tell us how this has changed the landscape of BPH symptom management and lower urinary tract symptoms. Please talk specifically about HoLEP as a surgical BPH treatment and what are the benefits?
Dr Amy Krambeck: Well, I may be biased, but I personally think that HoLEP is not the gold standard, but the platinum standard for BPH therapy. It has been more widely studied than any other surgical procedure for BPH. And there's been more randomized clinical control, trials, more meta-analyses, more case studies on HoLEP than any other surgery and outcomes are phenomenal.
Long-term data shows that the prostate, although it regrows throughout the course of your lifetime, it never gets big enough to re-obstruct again. So the retreatment rate after HoLEP is less than 1% with studies that go out to 18 years, which is almost unheard of. It's also exceptionally safe. It's one of the few treatments that you can do in the anticoagulated patient or the patients with bleeding disorders.
And there's no size limit for HoLEP. Any prostate is a candidate. There's no prostate that's too big or too small. So it's just a phenomenal therapy. Patients have been shown to have sustained relief of their symptoms and very short convalescent periods after the procedure.
Melanie: Isn't that interesting? So as long as you mentioned symptoms, is it true that men don't often seek treatment until their symptoms become quality-of-life-limiting? Tell us how you stratify symptom burden in your decision to use HoLEP and, while we're talking about utilization, why isn't it more popular or widely used among urologists?
Dr Amy Krambeck: Yes. To answer your first question, it is unusual that men do not seek treatment early. They tend to hide their symptoms for a very long time until it becomes a huge impact on their quality of life. I tend to stratify men into two categories. There's those that absolutely need surgery. They can't urinate. Their kidney function is damaged. They're having gross hematuria or they're having recurrent infections. Those men really have to have a surgical intervention. And then there's men that it's more of a quality of life issue. Like how many times are they getting up at night? Are they changing their daily activities to go to the bathroom? Are they having incontinence episodes? And those men also I tend to encourage them to seek surgical intervention too, especially if they've tried medication and failed.
The reason I feel that HoLEP is not more widely utilized is it takes a long time to learn how to do it and to do it well. So most people who do HoLEP have spent at least a year, if not longer, doing specialized training to learn how to do the surgical procedure. Once you master it, it’s very easy to replicate the good outcomes, but it takes about 50 to 100 cases to get to a point of minimal mastery to perform this procedure. So that's why it's not more widely utilized.
Melanie: Wow. So you just pretty much described maybe one of the disadvantages of the technique, but speak about the technique itself, Dr. Krambeck. And how does it compare to TURP?
Dr Amy Krambeck: With a TURP, you go in with a scope through the urethra and you shave out pieces of tissue or shave out pieces of prostate until you have an open enough channel for someone that you think could urinate. With HoLEP, it's completely different. You do go through the urethra with a scope, so it's a natural orifice surgery, but you're using the laser to cut like a knife. And you can actually peel a prostate, like you can peel an orange. So the knife cuts through to the capsule. And then you peel out all the adenoma like you're peeling off the rind of an orange and that's deposited into the bladder. And then you use a morcellator to chew up that tissue and remove it from the body.
So it's a phenomenal technique, phenomenal procedure. And there's really only one way to do it, just like there's only one way to peel an orange.
Melanie: Well, how does it also compare to MOSES enabled pulse laser modulation or MoLEP?
Dr Amy Krambeck: Yeah. So MoLEP is some phenomenal new technology that's currently on the market. And basically Lumenis has taken the holmium laser and modified the bubble formation so that you have better energy delivery to the capsule into the tissue. And that translates into a more efficient surgery. So it takes less time to do the procedure and it translates into less bleeding. So with the MOSES technology or what we call MoLEP, you're doing a HoLEP surgery, but you're using this new laser. And it results in being able to send the patients home the same day. You can take their catheters out the same day. You can safely treat people who are anticoagulated and there is no limit to how big of a prostate you can treat. So it's really advanced the procedure to the next level and made it exceptionally safe and efficient.
Melanie: Do you want to briefly please discuss your recent paper published in urology for us?
Dr Amy Krambeck: Yes. So in the most recent paper, we looked at the MOSES technology and compared it to standard holmium technology for HoLEP. And we found that when we use the MOSES technology or the MoLEP, the amount of time we spent trying to control bleeding was decreased, or enucleation time or the amount of time we were operating was also decreased. And we were more likely to be able to send the patients home the same day.
And that's just huge because if you look back 10 to 15 years, men with 100 to 200-gram prostates were spending, you know, several days in the hospital after an open suprapubic prostatectomy. Now, we're sending them home the same day and sometimes even without a catheter and no blood transfusions. It's really just taken a very complex clinical scenario and made it more safe and with minimal morbidity to the patient.
Melanie: So interesting. What an exciting time to be in your field, Dr. Krambeck. As we wrap up, is there anything else that you'd like providers to know about treating patients with BPH or when you feel it's important that they refer, and what you would like them to know as you join Northwestern medicine?
Dr Amy Krambeck: I like them to know that I'm very excited to be in Chicago and I'm here to help. So if you see a patient that has an exceptionally large prostate or who has failed prior BPH procedures, maybe they have an enlarged prostate, but an acontractile bladder or they're on complex anticoagulation, or have complex BPH and stone disease, please send them my way. These are the patients that do very well with the HoLEP surgery or the MoLEP surgery, and they can have an excellent outcome like everyone else.
Melanie: Thank you so much for joining us today and telling us about this fascinating new procedure. To refer your patient or for more information, please visit our website at NM.org/urology to get connected with one of our providers
That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts.
I'm Melanie Cole.