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My Background & Upcoming HoLEP — Would Love Your Insights
Hi everyone. I've been reading through this forum and am impressed by the depth of experience here. Wanted to introduce myself as I prepare for surgery this summer.
About me: 57-year-old, otherwise healthy male (BMI ~23). Progressive BPH/LUTS for several years (weak stream, straining, incomplete emptying, frequency, nocturia). IPSS 23 (severe). Currently on alfuzosin and tadalafil; previously tried tamsulosin and finasteride, both discontinued due to side effects.
Key findings: Cystoscopy showed a significant intravesical median lobe. Prostate ~40-50 cc on CT. Post-void residuals climbing into the 300+ mL range, and my latest renal ultrasound showed mild left hydronephrosis (likely from the outlet obstruction and drinking too much fluid pre-study). Bladder wall thickening also present. PSA consistently low (~1.0–1.2).
The plan: Scheduled for HoLEP with Dr. Amy Krambeck at Northwestern on July 10. I'm fortunate to be only ~2.5 hours away in central Illinois. Plan is outpatient, catheter-free discharge, with a hotel stay the night before and after as a precaution. I am trying to get mentally prepared for the recovery timeline, including (hopefully) transient incontinence and retrograde ejaculation.
Questions for those who've been through it:
1. For those with a prominent median lobe as the main component… did your recovery or symptom improvement differ from what's typically described?
2. What was your real-world timeline for regaining continence and ditching pads entirely?
3. Practical recovery tips you wish someone had told you beforehand, like pad recommendations, managing urgency spikes, activity pacing, etc.? I love exercising and use my elliptical five times a week and do weights 2-3 times a week. Laying off will be tough, but I know necessary.
4. For outpatient/no-catheter discharges, how did the first 48 hours go? Anything catch you off guard? When did you start taking some casual walks around the neighborhood?
5. How did you handle the caffeine restriction? I usually drink 2-3 cups a day. How long before you reintroduced coffee, and did it make a noticeable difference? How about soft drinks?
6. For anyone with elevated PVRs (300+ mL) pre-op, how quickly did emptying improve?
I'll be honest… I'm a bit nervous about all of this. Reading testimonials about prolonged incontinence and regret on this Forum has been sobering. Also, a couple of years ago, I had emergency kidney stone surgery that went sideways due to a surgical complication (sub-optimal surgeon), and that experience left a mark. I know there are no guarantees with any procedure, but I've done my research, I feel confident in Dr. Krambeck and the team at Northwestern, and at this point, there's not much more I can do except prepare and trust the process.
Thanks in advance. I'll continue reading existing posts and plan to share my own experience as I progress.
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Oh wow! This is awesome. Thank you so much! I put my NPI number in and it’s free for healthcare providers. I have never heard of open evidence. Thanks for the info.
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1 ReactionThanks for all your info. You and I have such a similar situation. I had a PVR of 202 cc. Thickening of the bladder wall. 1.2 mm bladder stone. Had HoLEP done July 17 from dr Mitchell Humphreys. I saw him 5/6/26 and had to wait over two months. He stated he has done 6,500 HoLEP surgeries. Gave me time to almost cancel. I was so worried about retrograde ejaculation and incontinence. Thought about aquablation. Not enough long term data for me and I don’t want to go through this again. You and I discussed the tamsulosin anejaculation. I believe and hope after HoLEP it will be different . My prostate was 72 cc. I watched a lot of videos from Dr. Krambeck. When I mentioned her to my dr, he said she trained with him. It’s been 3
Days and I can’t make it to the bathroom without pre and post dribble. I was told not to push and try to force my bladder to completely empty. May cause more bleeding. It’s mostly stress incontinence. Has that gone away for you? I’m planning to get back to work 7 days post op. I have my own bathroom right next to me. But I’m starting to worry it might be too soon.
@alfonse Thanks for the update. It really does sound like we had a lot of similarities leading up to surgery. My PVR was in the low 300s, and I also had bladder wall thickening from years of outlet obstruction, although I didn't have a bladder stone. I had been on Flomax and finasteride in the past and more recently was taking 10 mg of alfuzosin along with 5 mg of daily Cialis.
My prostate was actually fairly small overall. Dr. Krambeck removed about 7 grams of tissue, almost all of which was a very obstructive intravesical median lobe that was acting like a ball valve. Once that was removed, the improvement in flow was honestly startling. I don't think I've ever had a stream this strong.
I'm now 10 days out from surgery. I took the week after surgery off and went back to work today. My recovery has gone remarkably well so far, but I also realize every case is different depending on prostate size, anatomy, and how much tissue has to be removed. A larger gland leaves a larger healing cavity, so recovery can vary quite a bit.
Regarding your stress incontinence, I was fortunate not to experience much. I've had essentially no urgency or stress leakage, just a few drops remaining in the urethra after voiding that I shake out. I know many men do have temporary stress incontinence early on, though, and from everything I've read and from what my surgeon told me, it usually improves as the sphincter adapts over the ensuing weeks and months. I definitely would not judge your long-term outcome based on how things are at day 3.
One thing I've learned over the last 10 days is that recovery isn't perfectly linear. During the first week my urine gradually became clearer, but after becoming more active and returning to work today, I noticed a little more blood at the beginning of the stream with a couple of small soft clots. The middle of the stream remained clear, and the flow never changed. From what I've learned, the highest likelihood of a temporary increase in bleeding is actually during the second week as the healing tissue (eschar/scab) begins to slough, so I'm trying not to overreact to each individual void and instead pay attention to the overall trend.
As for returning to work after 7 days, I think that's a very individual decision. I felt ready, but I'm also not doing anything heroic and staying well hydrated. Having your bathroom right next to you is an advantage. I'd just listen to your body and not feel like you have to prove anything during that first week back.
I hope you have a smooth recovery. Please keep us posted on how you're doing. It's really helpful for all of us to compare experiences.
@wavelight2020 I spoke to the office today and got the all clear. This Friday will be four weeks since surgery.
@markbph1 congrats! And enjoy 😉
@wavelight2020
@wavelight2020
Your prostate was significantly smaller than mine. Actually got my pathology report back today. Prostate size was 72 and they removed 40 g of tissue. All which came back benign. So that’s great news. I’m just hoping this stress incontinence goes away quickly. I did read the Surgeon‘s report that said he did a mucosal sparing early apical release. He also stated that it was visually challenging for him because there was some blood that is consistent with a recent prostate infection. Then continued to say that there was still bleeding from the mucosal surface at the bladder neck was most likely secondary to inflammation of the prostatic tissue and rhe laser apparatus was replaced to get more hemostasis. Both urethral orifices were confirmed and identify well away from the area resection with no residual adenoma identified . I hope that doesn’t increase my risk of incontinence. It’s day four. As soon as I feel the slight urge to urinate, I get up and go. Can’t make it to the bathroom without a tiny dribble coming out before I get there. And the stream at this point is not strong. It’s consistent, steady flow and not a trickle. Maybe I still have tons of inflammation, but I was expecting a really strong stream. I guess time will tell.
@alfonse Congratulations on the benign pathology, that's great news and one less thing to worry about.
You also had 40 grams removed versus 7 grams in my case, so I think it's important to remember our recoveries may look quite different. My obstruction was almost entirely an intravesical median lobe acting like a ball valve, so I had a much smaller healing cavity.
I also wouldn't read too much into the wording of your operative report. The important points to me are that your surgeon identified and protected both ureteral orifices, achieved good hemostasis, and confirmed there was no residual adenoma. The inflammation and bleeding sound like routine operative findings rather than signs that something went wrong.
As for the stress incontinence, you're only on day 4. From everything I've read and from what my surgeon told me, it often takes time for the sphincter to adapt after the obstruction is removed. I wouldn't draw any conclusions this early.
Regarding the stream, mine was very strong immediately, but I don't think that's the expectation for everyone, especially after removing 40 grams. Swelling and healing can certainly affect flow early on. The fact that you have a steady stream rather than a trickle is encouraging.
I'm now 10 days out, and one thing I've learned is that recovery isn't perfectly linear. I actually had a little more bleeding today after returning to work, which fits with what I've learned about the second week, when the healing tissue (eschar) can begin to slough.
I couldn’t agree more. I had mild to moderate intravesical protrusion of the prostate into the bladder.. Which at first I thought was the same as a median lobe. But I was told it’s not. However, it also acted like a ball valve. When is your first follow up appointment? They haven’t even contacted me after surgery, except to send me t to send me a message from pathology on the patient portal. I was told I will have a follow up appointment three months from surgery. My concern is that my PVR was 202 before surgery. Which is what caused my bladder stone. But I can’t be sure that I’m completely emptying my bladder at this point. I just don’t want to develop more stones. You would think I would at least get a phone call asking how I’m feeling.
@alfonse My pre-op PVR was over 300 cc, so I understand the concern. Fortunately, my first two voids in recovery were measured before I went home, and my PVRs were only 31 cc and 74 cc, which was very reassuring. Since then, my stream has remained exceptionally strong, and my bladder feels like it's emptying almost completely.
My surgeon's office has been responsive to questions through the patient portal, but my formal follow-up is also at three months with Dr. Krambeck's PA. From what I've gathered, that's fairly common after an uncomplicated HoLEP.
If you're worried about whether you're emptying, it certainly wouldn't be unreasonable to send your surgeon's office a message. I'd think arrangements could be made for a quick bladder scan. Personally, I'd rather ask than spend weeks wondering.