Laser treatment for enlarged prostate
Professor Ahmed uses the Greenlight laser to vaporise enlarged prostates which are causing a blockage to urine flow.
What is a GreenLight laser photoselective vapourisation of the prostate?
It is an operation that uses a laser to remove excess tissue in the central part of your prostate gland. The laser uses concentrated light to generate precise and intense heat that vapourises the tissue. Tissue is not available for histology afterwards as it is vapourised. The procedure is also known as photo-selective vaporisation of the prostate (PVP).
Why do I need this procedure?
You usually have this procedure if you have benign (non-cancerous) swelling of your prostate gland. This can press against your urethra (the tube that drains urine from your body) and leads to symptoms such as making it difficult for you to urinate.
The procedure can also be used to ease the blockage caused by prostate cancer. We do not take out the whole prostate and it is not a cancer operation.
Professor Ahmed will discuss this with you at your first outpatient appointment and will talk to you about it again on the day of your operation.
What are the benefits?
• The operation removes the central part of your prostate gland, which should enable you to urinate better.
• It is a minimally invasive procedure so you will not have any cuts to the skin or stitches. There is an internal wound which heals slowly over a a few weeks.
• As the procedure is done in the afternoon or early evening at the Cromwell Hospital, patients stay overnight, so that the catheter that is placed through the urethra into the bladder during the end of the operation can be removed. Sometimes, the catheter needs to stay for longer and Professor Ahmed will advise you about this.
What are the risks?
These risks are common to TURP and laser TURP. Whilst the risks are reportedly lower for laser TURP than standard TURP, as with any risk they are not zero risk.
• Urine infection: about 1 in 20 men get a urine infection. Sometimes the infection can spread to the testicles resulting in something called epididymo-orchitis. Infection is usually managed with tablet antibiotics. Rarely, this can require admission for antibiotics through the vein due to sepsis. You will be given antibiotics just before the procedure through the vein and for 7 days afterwards as tablets to minimise this risk.
• Difficulty passing urine: You usually need a catheter (a bendy, hollow plastic tube that drains urine from your bladder) put in for this operation. This is removed at the Cromwell one or two days after. Most men – about 4 in 5 – will be able to go home without a catheter, but some may find it hard to pass urine when it is removed and need this to be replaced for a week or so afterwards to rest your bladder. This causes no long-term problems, but the catheter is uncomfortable and there is a slight risk of urine infection. You do not need to stay in hospital. Sometimes after you go home without a catheter, the flow of urine can seize up and you will then need to go to the local Accident and Emergency department to have a catheter fitted.
• Bleeding: although we do not make a cut in your skin, this is still an operation. You may have some bleeding during the surgery or later. The risk of needing a blood transfusion is less than 1 in 100, even if you are taking blood-thinning medication. There will be bleeding from the urine occasionally for up to 6-8 weeks and sometimes for up to 3 months as the internal healing occurs. Provided the urine clears, then there is nothing to worry about. If you have continual bleeding (which is not a pinkish tinge or light rose colour) throughout the urine flow throughout the day you should let your doctor or urologist know or go to A&E to be assessed. Rarely, we need to take you back to surgery to control the bleeding and even more rarely, if the bleeding cannot be controlled using a telescopic approach, an open operation may be needed as an emergency.
• Dry orgasm: this is the most common side effect. It is when your semen does not come out through your penis due to the tubes that deliver semen being blocked or the mechanism that pushes the semen fluid downwards into the urethra being disrupted by the operation. It affects up to 6 to 10 in 10 patients after PVP. We have ways of trying to reduce this risk that we will discuss with you but this will affect the success of the operation in terms of improving urine flow and bladder emptying. You may feel your orgasm is less intense, but you usually learn to appreciate the sensation again. Dry orgasm can cause sterility but you cannot use it as a form of contraception because some sperm may still come out.
• Erectile dysfunction or impotence: there have been a few reports of erectile impotence after this operation and it occurs in 1 in 20 patients, particularly if you had problems with erectile function before the operation or needed to use medication to help the function.
• Prostate regrowth: we do not remove your whole prostate gland, so tissue can regrow. With the TURP procedure, 1 in 7 patients need more (revision) surgery over a 10-year period because of prostate regrowth. About 1 in every 100 patients need revision treatment each year after GreenLight laser surgery, so about a 1 in 20 probability over 5 years.
• Scar tissue: As with TURP, scar tissue (called a stricture) may form after the operation. If this happens you will need an operation to put it right. The risk of this happening in the first year with TURP is 1 in 20 and with GreenLight laser surgery it is about 1 in 50.
• Incontinence of urine: The risk is 1-2 in 100 and occurs because damage can occur to the sphincter muscle that controls urine flow. Part of this muscle goes into the prostate and cannot be seen during the operation, so uncommonly the muscle can be damaged. We may suggest you do pelvic floor exercises while you are recovering from your procedure to help strengthen the muscles around your prostate and become fully continent more quickly. Rarely, if the incontinence of urine does not improve after a few months then an operation may be needed called an artificial urinary sphincter or male sling.
• Capsule perforation: This can occur where a tear in the lining of the prostate can occur because the laser effect has gone too deep. It occurs in 1 in 100 cases. If it happens, it might not be spotted during the operation and will require a catheter for 3-4 weeks during which time it heals. Rarely, the tear does not heal and a further operation may be needed.
What are the risks of an anaesthetic?
Straight after a general anaesthetic you may feel tired, dizzy or weak. You must have someone to collect you and stay with you for the first 24 hours. During the first 24 hours you should not:
• drive or operate any motorised vehicle or electrical equipment
• sign any legal documents or make important decisions
• drink alcohol.
You may feel weak or dizzy at times during the first 7 – 10 days. If this happens, sit down until the feeling passes. You may also have the ‘post-operative blues’ and feel a little depressed. If any of these symptoms do not go away, please contact you GP for help and advice. Rarely, a clot can form in the leg which can result in a clot in the lungs. We cannot give you blood thinning medication because of the risk of bleeding caused by these types of medication after a PVP operation. Chest infections can sometimes also occur and these will need antibiotics. The risk of mortality after a general anaesthetic or an operation like this is extremely rare.
What are the alternatives?
At your outpatient appointment your surgeon will have discussed with you whether you would prefer to manage your symptoms with medicine. There are other operations, such as standard TURP, Urolift, Steam (Rezum) therapy and prostate arterial embolization, that can be used to remove prostate tissue. Other types of laser can also be used to remove prostate tissue such as holmium laser enucleation or thulium. You may not be suitable for all of these options as it depends on your specific symptoms, any other problems you have, whether you have a catheter in place already and how long, and the shape and size of your prostate. Professor Ahmed will discuss which options are optimal for you based on your complete details.
You may have been taking medication to shrink or relax your prostate, or had these offered to you. These medications do not work for everyone.
If you do not have treatment and your prostate keeps getting bigger, it may stop you from passing urine. We can ease this for a short while by putting in an ‘indwelling’ catheter – a type of catheter that you can have in your bladder for a while to drain urine – while we decide whether you need surgery. Some men opt for self catheterisation on a regular basis.
What happens during the procedure?
You usually have a general anaesthetic for this procedure. If you have other long-term (chronic) medical conditions, such as problems with your heart or breathing, we may recommend you have a spinal (regional) anaesthetic instead with some sedation to make you comfortable. This means you have no feeling of pain from the waist down during the operation. If this applies to you the anaesthetist will let you know.
Once you are in the operating theatre:
• We will pass a telescopic instrument called a cystoscope into your urethra (the tube through which you pass urine) and up into your bladder to examine it. The cystoscope is 2-3 millimetres thicker than the thickness of a pencil and has a tiny video camera on one end, so we can view images of your urethra and bladder on a television screen
• We will vaporise the prostate tissue through the cystoscope using a high-powered laser.
• We will place a catheter in your urethra and bladder to drain urine for the first 12 to 24 hours after your procedure. This is because things can be sore and swollen and the bladder can often seize up if we did not place a catheter.
How long does it take?
This depends on the size of your prostate, but on average it takes between 45 – 60 minutes. You should expect to be in the hospital for 1-2 nights depending on what happened during the procedure and how quickly you are able to recover after the procedure.
What happens after the procedure?
If you had a general anaesthetic you will be go back to the ward for at least two – three hours because you will feel drowsy and need time to recover. There will be tubing that sometimes is connected to wash your bladder out so that clots do not form which can block the catheter or the urethra if they form. The irrigation is stopped slowly over a few hours. You will have the catheter removed the morning after or sometimes two days later. Your surgeon will advise on the timing of this. You will probably pass a little blood in the first few weeks, particularly when you start peeing. This is normal. If bleeding is a major problem, drink lots of water and have a urine sample checked for an infection.
You may not be able to pass urine after the operation. This is much more common if your bladder has been stretched or is emptying poorly before the operation. This will be discussed with you in detail at your appointment before your procedure.
It is normal to feel some mild discomfort. Most men need only simple painkillers to ease any pain, although some may need tablets to calm bladder spasm. About 1 in 10 men have burning in their penis for a few weeks after the operation; this is usually irritating rather than painful and always settles down.
You can usually leave hospital on the following day, once you have passed urine. If you require a catheter again, this is usually taken out the next week.
Getting back to normal
Most men find their symptoms improve by at least 50% within six weeks of surgery. As your bladder may be overactive for a few weeks due to inflammation after the operation, you might think things are getting worse before getting better. So, for a while, we advise you to avoid any long journeys where you cannot use the toilet. This will make it easier for you to go to the toilet when you want and help you to recover quicker.
Your bladder function can keep improving for up to six to nine months after the procedure. If urgency and getting up at night were major problems before your operation, or if you had any incontinence of urine, in addition to the obstruction caused by the prostate tissue, then these symptoms sometimes do not improve even if you bladder emptying does. This is because the bladder irritability often is long standing and becomes irreversible over time.
About 1 in 6 men still have these symptoms after the operation. If so, we will presume they are caused mainly by your bladder being overactive and offer you medical treatments to ease your symptoms. Over the long run, the symptoms can be caused by regrowth of the prostate tissue and you will then need to restart the medication of think about a further operation.
Work and leisure
You can go back to work when you feel fit. You usually need no more than a week off, depending on the type of work you do. Some men have gone back to work within 48 hours but only where it does not involve any manual labour.
We advise you to avoid very heavy lifting for 4 weeks after the procedure as this can cause bleeding.
You are fine to drive again provided you are able to safely carry out an emergency stop. It is important you check with your car insurer as some insurers have specific rules in their policies. You can start doing sport again after 4 weeks.
You can also start sexual activity as soon as you feel able. You are likely to notice blood in your semen or discoloured semen if you ejaculate normally. This is nothing to worry about and will not harm your partner in any way. Orgasm might be uncomfortable or painful but should improve over time as the inflammation settles. Some men find they get ongoing discomfort in their testicles after this operation.
Will I need to come back to the hospital?
We will ask you to come back after 12 weeks. We may ask you to carry out another urine flow rate and bladder scan. You may also need to have blood tests. Depending on your recovery, you may need to have these checks again six or 12 months later.
After that time your GP can usually check your progress, although we may ask you to have some tests again.
Greenlight Laser for enlarged prostates is available privately under Professor Ahmed’s care.
For referrals, Professor Ahmed works at Cromwell Hospital and Imperial Private Healthcare. Self-pay patients do not need a referral to consult Professor Ahmed and there are competitive self-pay packages offered. Insured patients should check with their insurer.
Please use the online booking portal or email the team on firstname.lastname@example.org