.png){kind=small}
.png){kind=small}
BackTable / Urology / Article
HoLEP Side Effects: Strategies to Manage Incontinence & Leakage
Javier Prieto III • Updated Mar 8, 2025 • 33 hits
Holmium laser enucleation of the prostate (HoLEP) is increasingly recognized as a valuable surgical treatment for benign prostatic hyperplasia (BPH). While traditional approaches such as aquablation, prostatectomy, and transurethral resection of the prostate (TURP) remain widely used, HoLEP has gained attention due to its superior long-term relief of bladder outlet obstruction and lower retreatment rates. However, emerging research highlights incontinence as a significant postoperative side effect, with patients commonly reporting persistent leakage, as well as stress and urge incontinence.
Post-operative monitoring of incontinence should begin immediately and is manageable for most patients, though the severity and duration of symptoms can vary based on individual factors. In this article, Dr. Spencer Hiller and Dr. Jose Silva provide an in-depth explanation of the mechanisms underlying incontinence following HoLEP, and explore evidence-based therapeutic options for patients with persistent symptoms. They also share key considerations in the post-operative recovery process, including hospital discharge protocols, patient activity levels, and voiding trials, offering strategies to optimize patient outcomes and minimize HoLEP side effects.
This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Urology Brief
• Post-HoLEP incontinence, often due to external sphincter weakness exacerbated by surgery, typically resolves within 12 weeks with Kegel exercises. Persistent incontinence beyond eight weeks may require referral to pelvic floor physical therapy.
• Catheterization after HoLEP can often be avoided if there is a successful voiding trial on the day of surgery. Voiding trials are considered standard in HoLEP post-operative care, though logistical delays may necessitate next-day trials.
• In the case of persistent post-HoLEP urge incontinence, it can be challenging to determine when to initiate treatment. Approaches vary by provider, with some recommending to delay pharmaceutical intervention for as long as three to six months. Tailored therapeutic options, including bladder retraining and pharmacological treatments, aim to improve outcomes and restore quality of life.
Table of Contents
(1) How Long Does Incontinence Last After HoLEP?
(2) Managing HoLEP Side Effects: The Standard Post-Operative Protocol
(3) HoLEP Long-Term Side Effects: When to Initiative Treatment
How Long Does Incontinence Last After HoLEP?
Most patients undergoing HoLEP achieve a full recovery within several weeks post-surgery. However, incontinence remains a growing concern among urologists, with 1-2% of patients experiencing permanent leakage. Transient incontinence, characterized by stress incontinence, is commonly expected and typically persists for approximately 12 weeks. This can be a source of frustration for patients, as the condition significantly impacts their quality of life.
A primary contributor to post-HoLEP incontinence is external sphincter weakness. Many patients have never previously relied on their external sphincter to such an extent, and the additional weakening caused by surgical manipulation exacerbates the issue. There is ongoing debate within the urology community regarding whether this incontinence arises primarily from surgical trauma to the sphincter or preexisting weakness that becomes apparent postoperatively.
To address this complication, Kegel exercises are widely recommended both pre- and post-operatively. Patient education on proper technique is essential, as the benefits of these exercises depend on consistency and correct execution. Patients should be instructed to contract the same muscles used to stop urinary flow, performing 10 sets of 10 repetitions daily. Regular practice of Kegel exercises can significantly strengthen the external sphincter, enabling many patients to overcome incontinence.
For patients who continue to experience incontinence beyond eight weeks post-surgery, referral to pelvic floor physical therapy is advised. This intervention can provide tailored strategies to alleviate persistent symptoms, ensuring comprehensive care and improved patient outcomes.
[Dr. Jose Silva]:
Let's talk about who's a candidate. Once the patient gets there, is there something different that your speech to the patient versus when you were in residency talking about TURP?
[Dr. Spencer Hiller]:
Most of my discussion with the patient before surgery is related to the mostly transient incontinence that occurs after HoLEP. It's something that I really worry about. Every single case is, "How long is this guy going to leak for?" I prepare every patient to say, "You might be in the 1-2% that leaks permanently. I don't expect it. What I do expect is that you could leak urine for up to 12 weeks afterwards. And that's usually my threshold for timing that I say, you know, we're beyond the expected short-term leakage.
[Dr. Jose Silva]:
And we’re talking all leakage, you're talking about stress incontinence.
[Dr. Spencer Hiller]:
That's a really good question. I think it's a little bit of both. I think there's a huge urge component related to this. Just most of these guys have very strong bladders. And when they get an urge to urinate, their external sphincter, which they've never used, aside from maybe trying to stop the flow to go answer the doorbell or something, is not strong enough to overcome how strong their bladder is for the 75 years it's been working.
I think a lot of the leakage has been historically with HoLEP attributed to weakness in the external sphincter related to the surgery, which I think is true. I do think that there's a big component just related to urge and the inability to adequately stop that external sphincter.
[Dr. Jose Silva]:
In terms of kegels, preoperatively, for example, is that something you tell the patients that they should start doing it?
[Dr. Spencer Hiller]:
Yes. Everybody gets a Kegel exercise handout from me, be it either pre-op or post-op. I tell them when they are leaving the hospital, if they have not already started Kegels, to start doing them day one. My standard is that when I see them post-operatively eight weeks after surgery, if they're having any leakage and they're bothered by it, I will refer them to Pelvic Floor Physical Therapy. I'm pretty aggressive about Pelvic Floor Physical Therapy. If they contact me before that eight-week time point about leakage or bother from it, I will go ahead and refer them to Pelvic Floor Physical Therapy.
[Dr. Jose Silva]:
When you're talking about that patient in terms of the stress incontinence, why do you think that happens? It's just because the aggressive nature of the opening that you're creating with the HoLEP?
[Dr. Spencer Hiller]:
Yes, is part of it. I think most guys don't know how to work their external sphincter like they need to after a surgery like this. When you're trying to explain to your average patient that the Kegel exercises are simply to strengthen that muscle so that it can get you to standing over the toilet when you have that urge, they have a hard time understanding that they have to squeeze that muscle the whole way there.
Maybe six months, I didn't really piece it together that most guys, when they're doing the Kegel exercises, think that all they have to do is be squeezing it sitting on the couch. Then when they get that urge to urinate and they stand up, they didn't understand that the whole point of the exercises is so that they have sufficient strength in their external sphincter to get them to the toilet. It's a lot about patient education. I draw a lot of diagrams for patients and talk to them about this extensively. I think some people it sticks, some people it doesn't. That's where physical therapy really comes in.
[Dr. Jose Silva]:
How do you tell the patient to do the Kegels? What's the correct way of doing them?
[Dr. Spencer Hiller]:
I will usually tell guys to figure out what muscle you're supposed to squeeze. I want you, while you're urinating, to stop the flow of urine and cut it off. When they're able to do that, I say, "You've found the muscle. Now, when you're sitting on the couch, riding in the car, even right now during a conversation, I want you to squeeze that muscle 10 times and do that 10 times a day, if not more.
[Dr. Jose Silva]:
Okay. The transient leakage incontinence is essentially a weakness of the sphincter, not really related to damage to the sphincter.
[Dr. Spencer Hiller]:
I don't know if I would go so far to say that there's no damage to the sphincter. There's a lot of technical things that I've tried to incorporate in how I do this procedure to try to minimize damage to the sphincter. There's a lot of discussion in en bloc HoLEP or early apical release in liberating that distal part of the adenoma off of the sphincter as early as possible to minimize the trauma. I will say that for the listeners, there's definitely some trauma. My hope is and what I'm trying to achieve is that it's transient damage, not permanent damage, but it's hard to say.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Managing HoLEP Side Effects: The Standard Post-Operative Protocol
Urinary leakage is a common complication associated with HoLEP procedures, with varying outcomes and recovery trajectories among patients. Approximately 50% of patients can be discharged on the same day as the procedure, contingent upon the success of a voiding trial. This percentage might be higher if not for logistical delays, such as procedures performed later in the day, which necessitate postponing the voiding trial until the following morning when a full medical staff is available. Successful voiding trials significantly reduce the likelihood of patients requiring catheterization upon discharge, a key determinant of favorable outcomes.
Research consistently underscores the importance of performing same-day voiding trials, which are widely regarded as a standard protocol in HoLEP post-operative care. However, in certain cases, catheterization remains necessary—particularly for patients who fail the voiding trial or for elderly individuals with limited support at home. Discharge can also be delayed by clinical observations such as hematuria, which warrants further investigation to rule out complications. The primary objective for all HoLEP patients is to achieve a robust urinary stream as soon as possible post-operatively, signifying a positive recovery trajectory.
Catheter removal strategies also vary among providers. For example, Dr. Amy Krambeck advocates for having patients ambulate and perform physical movements before catheter removal, utilizing gravity and bodily motion to facilitate urinary flow. Conversely, some practitioners opt for bed rest with three-way irrigation systems, though this approach can introduce challenges, such as managing tangled tubing and associated inconveniences. These differing techniques reflect the individualized nature of post-operative management strategies aimed at optimizing recovery and minimizing complications.
[Dr. Jose Silva]:
That same day? They're going home without a catheter?
[Dr. Spencer Hiller]:
Yes. Yes. Then the other 50% will spend the night with the catheter and then it comes out in the morning and they go home without a catheter. It's very rare that guys have to go home with a catheter.
[Dr. Jose Silva]:
Is it based on size or based on anatomy or a combination of both?
[Dr. Spencer Hiller]:
Whether or not they stay?
[Dr. Jose Silva]:
Yes. Yes, or the fact that they stay with a catheter or not?
[Dr. Spencer Hiller]:
Honestly, the reason that they stay is time of day that the surgery happens. I'm doing the voiding trial for most of these guys myself and if it's late in the day and I don't have the ability to come back in and do the voiding trial at night. I'll offer it to my first couple of cases of the day, but once we get into the afternoon, it's just going to be too late. Most of them don't want to have to drive home at night or have their wife drive them home at night where it's dark.
[Dr. Jose Silva]:
Exactly. Yes. Before I was doing a lot of GreenLight, they went home with a catheter next day, voiding trial. Now with doing more of the aquablation, they stay two days with the catheter. That's what I was doing for TURP, so that's what I've been doing now.
[Dr. Spencer Hiller]:
I don't know how it is for aquablation. I know that it's rare with the voiding trial that it has to go back in. Are you doing that in the office or in the hospital before they leave?
[Dr. Jose Silva]:
It depends. If sometimes they live alone, they don't want to leave with a catheter, I keep them for two days and then I do it there in the hospital. If not, next day they go home and probably start trying to get them discharged the same day and then come back to the office two days afterward to remove the catheter, but we'll see how that goes.
Like you mentioned, you're doing the voiding trial yourself, getting that, the hospital training and everything to do keep doing irrigation for a few hours and then seeing if they can be off the irrigation, it's going to be challenging to train the personnel. We'll see how that goes.
[Dr. Spencer Hiller]:
I've been very protective over the actual voiding trial process of it since starting down here. Where I trained, they had a whole army of PAs that had been well-trained by my Fellowship Director on the voiding trial. When I got down here, I was very protective over it and I do actually think that it makes a little bit of a difference.
If their urine looks appropriate, I'm inflating the balloon, I'm irrigating the bladder, I will pull back the catheter into the fossa and pretty aggressively irrigate the fossa to make sure there's not a distal clot that when I take out that catheter is going to plug them up. Then I will fill them to capacity and take it out.
What I really want is them to have a pretty strong stream immediately as soon as that catheter comes out.I've been surprised how often, even though I tried so hard to get rid of every little blood clot in there, in the fossa, there's still something that comes out when I do that. I found that it works pretty well. Now do I have to do all that? I don't know. It's just what I've found works for me.
[Dr. Jose Silva]:
No, you sleep better knowing that the patient voided instead of going home and seeing what happens. You trained what they were doing or that's something that you started doing yourself?
[Dr. Spencer Hiller]:
I don't know that during my fellowship I did any of these voiding trials that I can remember. That really wasn't part of it. That was something I had just had to figure out when I got down here.
[Dr. Jose Silva]:
Why did you start doing it just like they did that voiding trial the same day to be different? You heard other people are doing it? What made you try to do that?
[Dr. Spencer Hiller]:
Yes, same day discharge for HoLEP is definitely a known entity and some people have published criteria. Most of the literature that comes out regarding HoLEP comes out of Indiana, although I guess now Northwestern as well. There's certain criteria. I don't really follow a certain criteria. A lot of it is just an eyeball test.
I mean, "Does this guy look like he could go home from the hospital the same day as surgery?" If I don't think that they look like they would do well at home, then I say, "You should stay." Then some of it's just how their urine looks, if they're bloody, and we can always pivot to having them stay. It's hard to get them out the same day if they're already up on the floor though.
[Dr. Jose Silva]:
In terms of the foley, is that something that you started doing? Also that that's the trend, try to remove those guys the same day?
[Dr. Spencer Hiller]:
Yes. I'm certainly not the first person to try that. We dabbled with it a little bit in my fellowship. During the second half of training, I know that there was some of the first studies coming out of Indiana with some criteria. We tried it out. You have to have a recovery area that's willing to have these patients sit there on an irrigation for a while.
I'm fortunate that that hasn't been a problem for me. It was actually a little bit of a problem in my training and figuring out where these patients would sit for a couple of hours on the irrigation afterwards. Sometimes it's not that long. I have some guys that are on irrigation for just like an hour and then they're ready. They're crystal clear and they're awake and they want to go.
[Dr. Jose Silva]:
Cool.
[Dr. Spencer Hiller]:
I think it's Amy Krambeck had some criteria, she has them walk before she will do the voiding trial. I have not been able to figure out how to get the patients to walk before, especially on the same day, able to remove it. I don't know how that would work. I really try to have these guys stay in bed while they have the three-way in on the irrigation. It's something that I think about trying to figure out.
[Dr. Jose Silva]:
I guess it will be to see if there's some bleeding or something so it bleeds before.
[Dr. Spencer Hiller]:
I think it maybe increases their chances that they're going to be able to go because they can stand up to urinate. Nobody urinates while laying flat on their back. Knowing that they're going to be able to hop out of bed, once that catheter comes out, I think that's probably the thought process behind it. Logistically trying to get it done while they still have that three-way in and the irrigation tubing, it's always a mess in there when I'm trying to do these voiding trials and trying to untangle all the tubing and stuff.
[Dr. Jose Silva]:
In terms of, you mentioned the distress incontinence, everybody leaves with a diaper?
[Dr. Spencer Hiller]:
Yes, I tell them to be prepared for it. The recovery area has something that those big male diapers that we've all seen or some of them come prepared with something from home. There are definitely patients that never leak a drop. Don't think that everybody is going to leak for three months. Most guys, especially that first week or two, are going to leak. I think my experience is that he number improves. I will tell them that, "Approximately, 50% of guys by maybe two, maybe four weeks are mostly dry." Then that number continues to go up with time.
HoLEP Long-Term Side Effects: When to Initiative Treatment
Following the post-operative period, some patients experience persistent incontinence, which may manifest as urge incontinence. A significant challenge for physicians is determining the appropriate timing for initiating medical treatment, particularly when urge incontinence severely diminishes a patient’s quality of life. Currently, there is no standardized protocol for managing urge incontinence in these cases, and treatment approaches vary among providers. A common recommendation is to delay pharmaceutical intervention for approximately three to six months post-surgery to allow for natural recovery and adjustment.
The primary goal during this period is to retrain and strengthen the bladder. This is necessitated by the stress exerted on the bladder during the HoLEP procedure and the lack of prior conditioning of the external sphincter. Several therapeutic options are available for addressing post-operative urge incontinence. Pharmacological treatments include anticholinergic agents such as oxybutynin and beta-3 adrenergic receptor agonists like mirabegron, both of which work to relax the bladder and alleviate symptoms. Additionally, botulinum toxin (Botox) injections have shown strong evidence of efficacy in reducing urgency and leakage by relaxing the bladder wall. These therapeutic options provide physicians with a range of strategies to improve outcomes and restore quality of life in affected patients.
[Dr. Jose Silva]:
In terms of the urge, when do you decide, "Okay. Let's start someone with anticholinergics," be the three agonists? Is there a time or is it just the patient that is calling you, "Hey, I cannot hold it anymore," or, "I'm going to urinate every half an hour"? How do you decide which one to treat and which one just to wait?
[Dr. Spencer Hiller]:
Yes, I really tried to counsel these guys to wait. I don't know that this is based on any real evidence and it's just how it makes sense in my mind. I want their bladder to retrain itself. I feel like adding in a beta agonist or an anticholinergic is just putting a Band-Aid on a wound and not letting it heal.
I want them to have to, I hate to say this, but to suffer through that period of the urge incontinence so that they can retrain. Now, there's a point where they say, "Hey, I'm having significant urge incontinence," and I try to tease out whether it's stress or urge. If I really feel like it's urge, I will absolutely start them on something. I try to wait at least three months, if not six months. I think more often six months.
[Dr. Jose Silva]:
I tend to give them something, even though I tell them beforehand, "Hey, this might happen." I explain, "Hey, your bladder has been contracting against a rug or obstruction, now it's open." I think they feel better if I give them a pill.
[Dr. Spencer Hiller]:
I think you're probably right.
[Dr. Jose Silva]:
It's true what you're saying. I don't know what's right. I guess in my mind, if I give them something and I tell them, "Hey, it's just going to be temporary," maybe they feel that I care. Who knows?
[Dr. Spencer Hiller]:
I think you're right. There's pretty good evidence for doing a Botox at the time of HoLEP for guys that have a lot of urgency symptoms. I don't know that that's long-term data or not. I wouldn't say that I'm well-read on that enough, but I know that it works. I've done it a couple of times and it works. I don't know that I'm doing the right thing with that, if you want me to be honest. In my mind, I feel like I should be letting them retrain their bladder. I don't know that giving them a beta-3 agonist really prevents them from doing so. That's a good question. I don't know that it's right or wrong. Hopefully, somebody will tell me.
[Dr. Jose Silva]:
I usually give them whatever I have on the shelf. "Take this for a couple of weeks and we'll see."
[Dr. Spencer Hiller]:
Maybe I should start doing that. If you can't tell, I like trying new things.
Podcast Contributors
Dr. Spencer Hiller
Dr. Spencer Hiller is a urologist and clinical lecturer with University of Michigan Medicine.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2024, June 25). Ep. 174 – HoLEP: Advanced Techniques & Patient Outcomes [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
HoLEP Procedure Steps: Equipment Selection & Surgical Technique