My Background & Upcoming HoLEP — Would Love Your Insights

@wavelight2020
OK, that’s good to know. I guess three months follow up is common from what I read as well. However, my Post surgery PVR was 274 the first time, because I was afraid to push. The second time it was 147 so they decided that that was good enough. I sent the surgical team a message. Let’s see what they say. I’m on day five and the flow seems to be getting better. My main concern is the fear of developing another bladder stone. I definitely don’t want anything else going up my urethra for a long time! But from everything I researched it seems like I’m right on track. I’m glad you were able to go back to work. I know you mentioned you had some more blood in your urine. Which is obviously going to happen when you’re moving around more. We can have some bleeding even months from now. I have no problem laying down. I slept all night with no incontinence issues. I didn’t have to get up in the middle of the night to urinate. Walking around is not a problem. It’s sitting down that kills me. I guess I need time for that raw tissue to heal. Again, thanks for all your info. I’m sure we’re not only helping each other, but hopefully everyone else.

Three-Week HoLEP Update (Dr. Amy Krambeck, Northwestern)

I wanted to provide a summary now that I've reached the three-week mark, since reading other patients' experiences was incredibly helpful to me before surgery.

Background: I'm 57 years old. My prostate was actually relatively small overall, but I had a very obstructive intravesical median lobe that functioned like a ball valve and caused significant bladder outlet obstruction. My PVR was over 300 cc, with bladder wall thickening from years of incomplete emptying. I had previously tried Flomax and finasteride and most recently was taking alfuzosin 10 mg plus daily Cialis 5 mg.

Dr. Krambeck performed my HoLEP in about 35 minutes under MAC (monitored anesthesia care--"twilight"--not general) without complications. Only about 7 grams of tissue were removed because my gland was small and the obstruction was almost entirely that median lobe.

Recovery: I was discharged the same day without a catheter after two successful voids in recovery, with low post-void residuals (31 cc and 74 cc). From the very first urination, my stream was dramatically stronger than anything I'd experienced in years.

I took one week off from work and returned on postoperative day 10. During that time I took it easy, but I walked daily. I kept my 32 oz tumbler full of water and sipped it throughout the day.

Over the first two weeks, I experienced what I would consider an uneventful healing course:

-- Mild burning that resolved quickly (I used pyridium for only two days)
-- Intermittent pink urine.
-- Several episodes of passing small, soft clots.
-- I had early discomfort with erections, presumably from irritation of the urethra and surrounding tissues from the scope, etc. That largely resolved after two weeks.
-- Around postoperative day 16, I had one larger episode of clot passage with brief bright-red bleeding. I rested and hydrated, and everything cleared. This seemed consistent with eschar (healing tissue) sloughing, which commonly occurs during the second-third week after HoLEP.

I never developed urinary retention, significant pain, fever, bladder spasms, or meaningful incontinence. My stream remained consistently excellent throughout.

Today (3 weeks): Urine is essentially clear, clotting has stopped, there's no discomfort, and my urinary stream is honestly astonishing. My bladder feels like it's emptying almost completely every time. What used to take me 3 to 5 minutes is now done in 15-20 seconds.

I have ramped up my physical activity and started lightly using my elliptical trainer a couple of days ago without incident. I've also started back with weights, but I'm not pushing to my previous levels quite yet. I haven't resumed sexual activity, as I was advised to wait at least three weeks, so I can't comment on that aspect of recovery.

I also want to emphasize that every HoLEP is different. Someone having 40–80 grams removed will likely have a different recovery than someone like me who had only 7 grams removed. Anatomy, prostate size, surgeon experience, and the amount of tissue removed all influence recovery, so my experience shouldn't be viewed as the expected outcome for everyone.

For me, however, choosing HoLEP has been one of the best medical decisions I've made. I hope this timeline helps reassure someone who is preparing for surgery or is in the early stages of recovery.

I'm looking at ho-lep as a possibility for my BPH and 4+3 PCa. I'm 80 and the BPH isn't terribly problematic for urinary issues, but my large prostate (114cc) makes several PCa treatments "unadvisable." So I may approach the cancer in a two-step process: reduce the size of the gland (ho-lep or another ablative treatment) and then consider PCa treatment options (e.g., radiation or focal therapies).

@wavelight2020 See attached - I emailed that to the urologist earlier this week - to report my post Holep 5 week recovery window, Since day 28, I have resumed running; ran 4 times so far and absolutely no problem - no sudden urgency to wee in the middle of run! No blood in urine after running. I did not even wear Depends when running! Have stopping wearing them during the day time, and only wear them for sleeping.

Just beyond the one-month post-HoLEP mark, and things continue to go exceptionally well. If someone had told me beforehand that this would be my recovery experience, I would have signed up without nearly as much anticipatory anxiety.

My stream remains exceptionally strong, urine is clear, and I have no spasms, discomfort, or meaningful urinary issues.

The latest milestone was resuming sexual activity. I ejaculated for the first time this past week and, admittedly, I was a little nervous. It was completely uneventful. Since then, I’ve had several orgasms without pain, bleeding, or any other issue.

As expected after HoLEP, I now have retrograde ejaculation… There is essentially no visible ejaculate because it goes backward into the bladder and is later eliminated with urination. For me, this has turned out to be a complete non-issue. Orgasmic sensation and intensity are every bit as enjoyable as before surgery. In fact, being off the alpha blocker may have helped in that regard.

For anyone approaching this stage of recovery and worrying about what retrograde ejaculation will actually feel like: my experience has been that the anticipation was much more significant than the reality. Once I knew everything worked normally and comfortably, I stopped thinking about it.

Enjoy the newfound flow. The rest, at least in my experience, comes naturally.

@wavelight2020
Hello. I am glad to hear how well u are recovering. We have chatted before. If you recall same age, same issue but 40 grams removed. I am 3.5 weeks post op. I unfortunately still have stress incontinence and wear at least 2 pads per day. However I sleep all night with no leakage and it probably the only time my bladder actually has time to “completely” fill. During the day if I feel a drip I run to the bathroom and void what little urine has built up. It is definitely getting better. At first I was using up to 4 pads per day. No problems with erections. However, I have not tried to ejaculate yet. I was told to wait at least 4 weeks. I kind of nervous to try. The whole retrograde ejaculation thing has me stressed. I’m sure i’ll get used to it. I just hope it feels like a normal orgasm. With me developing bladder stones, and having bladder muscle tissue damage, I know this was the right option for me with the best long-term results. As far as the incontinence is concerned, my surgical team is doing a voluntary study on an EMSELLA chair. It provides electromagnetic impulses to the pelvic floor muscle tissue. I’m on the fence on whether or not I should volunteer. Does anybody know or have any experience with this?

@alfonse I can hopefully reassure you a little about the orgasm issue. I was nervous the first time too, and in retrospect the anticipatory anxiety was the biggest obstacle. My surgeon cleared me at two weeks, although I personally waited until a little beyond three weeks. Since your team told you four weeks, I’d follow their recommendation.

Once you’re cleared, though, I wouldn’t let the retrograde aspect occupy too much space in your head. The orgasmic sensation itself doesn’t depend on semen exiting through the urethra. In my case, the orgasm feels every bit as normal and intense as it did before surgery… the only meaningful difference is where the ejaculate goes. After the first time, when I realized everything felt completely normal and nothing bad happened, the anxiety disappeared and subsequent experiences were much more enjoyable.

I’m also back to unrestricted workouts, including fairly intense cardio, which has been another great milestone.

I do want to emphasize that I’m not posting my progress as a comparison or suggesting anyone else’s recovery should look like mine. I was fortunate to have an excellent surgeon, only about 6 grams of tissue removed, and a very short operation of roughly 35 minutes. You had about 40 grams removed, so we’re starting from very different positions on the track. Everyone gets to move forward at his own pace.

I think it’s valuable for these communities to include the positive experiences along with the difficult ones. Hopefully mine gives you a little less to worry about as you approach that next milestone.

@wavelight2020
That’s reassuring. Thank you! I actually asked my surgeon (Dr. Mitchell Humphreys) if he knew about Dr Amy Krambeck. He stated that she worked with him at Mayo. Dr Humphreys has Done about 7,000 HoLEP surgeries. I hope people that read our posts, understand how important the skill set is of the surgeon is when it comes to this type of surgery. It sounds like you and I had one of the best and most experienced HoLEP surgeons. I’m glad you’re doing well.

Small world! The urologist who ultimately recommended HoLEP to me is the chair of urology at SIU in Springfield and is good friends with Dr. Humphreys. In fact, he offered to personally call him and arrange things if I decided to go to Arizona. I ultimately chose to drive a couple of hours north to Chicago instead, but Dr. Humphreys was very much on my short list. So yes, you were definitely in excellent hands as well.

And I completely agree with your larger point. With HoLEP, surgeon experience and technique matter enormously. Hopefully our experiences encourage people considering the procedure to spend as much time choosing the surgeon as they do worrying about the procedure itself.