Holmium laser bladder neck incision

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your urologist or nurse specialist as well as the surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your urologist or specialist nurse.

What does the procedure involve?

This involves telescopic laser incision through the prostate and bladder outlet to widen the urinary channel with temporary insertion of a catheter for bladder drainage.

What are the alternatives to this procedure?

Drugs, use of a catheter/ stent, observation or conventional bladder neck incision using electrical current rather than a laser.

What should I expect before the procedure?

If you are taking a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban, clopidogrel, ticagrelor or any other blood thinning medication

you should ensure that the urology staff are aware of this well in advance of your admission.

You will usually be admitted on the day of surgery. Your general fitness, to screen for the carriage of MRSA will be assessed and sometimes some baseline investigations performed prior to your admission. This can, on occasions, be done by telephone or you may be asked to attend a pre-admission clinic approximately 14 days before your admission, depending on your medical history.

After admission, you will be seen by members of the medical team which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

Please be sure to inform your urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban,clopidogrel , ticagrelor or any other blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

Either a full general anaesthetic (where you will be asleep throughout the procedure) or a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you.

The operation, on average, takes 10 to 20 minutes.

You will usually be given an injectable antibiotic before the procedure after checking for any drug allergies.

The laser is used to incise through any tight areas in the bladder outlet (bladder neck) and prostate. Often, this allows sufficient widening of the urinary channel but, sometimes, a small amount of prostate tissue is removed at the same time to ensure the channel is clear and open. A urethral catheter is left to drain the bladder at the end of the procedure. The holmium laser is very effective at sealing blood vessels off as the procedure is being done.

What happens immediately after the procedure?

It is normal to see some blood in the urine initially after the operation as even a few drops of blood are enough to be visible in the urinary stream. Although the urine is usually clear of blood within the first week, do not be concerned if you notice some blood in the urine intermittently during the first 6 weeks. This often occurs as the prostate and bladder neck are healing. It is very rare to require a blood transfusion due to significant bleeding after laser bladder neck incision.

It is useful to drink between 3-4 litres of fluid every 24 hours for as long as blood is visible in the urine as this helps to clear the blood. Sometimes, fluid is flushed through the catheter while you are still in hospital after the procedure to help clear the urine of blood.

It is fine to eat and drink as soon as you feel you’d like to after the operation.

Most patients can be safely discharged on the same day as the surgery with the catheter left in for up to 1 week to allow any internal swelling related to the surgery to resolve. When you return to the ward after surgery, the nurse will show you how to look after the catheter at home. The colour of urine draining through the catheter will be monitored by the nurse and any temporary fluid running through the catheter will be adjusted and stopped as appropriate. Once we know that you can eat and drink without feeling sick, that you can get out of bed and walk safely, and that you know how to look after the catheter at home, you can be discharged.

Before you leave the hospital you will be given written information on who to contact if you have any questions or problems after you leave the hospital. You will also be given information on who will remove the catheter for you and when. Sometimes we arrange for catheters to be removed in the community, and sometimes you will be asked to return to the hospital for catheter removal. Full instructions will be given to you about what has been arranged in your case.

Before you come in for surgery please ensure you have made arrangements for the following:

• Someone is able to drive you home on the day of your surgery.

Someone will be able to stay with you the first night after surgery.

For some patients, going home on the same day as the surgery is not appropriate or feasible. The final decision on whether you are suitable for same day discharge is made on the day of surgery. Please come prepared to stay one night in hospital in case this might be necessary.

What to expect on the day your catheter is removed

At first, it may be painful to pass urine and it may come more frequently and urgently than normal. Any initial discomfort can be relieved by taking regular paracetamol and ibruprofen tablets. Any urinary frequency and urgency usually starts to improve within a few weeks.

Some of your pre-existing urinary symptoms, especially frequency, urgency and getting up at night to pass urine, may not improve for several months because these are often due to bladder overactivity (which takes time to resolve after prostate surgery) rather than prostate or bladder neck blockage. It is not unusual for your urine to turn bloody again for the first 24 to 48 hours after catheter removal. Some blood may be visible in the urine even up to six weeks after surgery but this is usually not a problem.

Are there any side effects?

Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Common (greater than one in 10)

• Temporary mild burning, bleeding and frequency of urination after the procedure
• No semen is produced during an orgasm in approximately 10%
• Infection of the bladder, testes or kidney requiring antibiotic treatment
• Need to repeat the procedure, or consider a different prostate procedure due to re-obstruction (approximately 10-20% within 10 years of the procedure).

Occasional (between one in 10 and one in 50)

• Treatment may not relieve all the urinary symptoms
• Weakened erections (impotence) in approximately 2%
• Injury to the urethra (water pipe) causing delayed scar formation (urethral stricture) in around 2%

Rare (less than one in 50)

• Bleeding requiring a return to theatre and/ or blood transfusion (less than 0.5%)

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

Most patients feel tired and below par for a week or two.

What else should I look out for?

If you experience increasing frequency, burning or difficulty on passing urine or worrying bleeding, contact your GP.

In the event of severe bleeding, passage of clots or sudden difficulty in passing urine, you should contact your GP immediately or attend the Emergency Department since it may be necessary for you to be re-admitted to hospital.

Are there any other important points?

Incision of your prostate should not adversely affect your sex life provided you are getting normal erections before the surgery. Sexual activity can be resumed as soon as you are comfortable, usually after two weeks.

Most patients require a recovery period of one to two weeks at home before they feel ready for work. We recommend two weeks’ rest before resuming any job, especially if it is physically strenuous and you should avoid any heavy lifting during this time.

Driving after surgery

As long as you feel safe to drive you could resume driving after 2 days of having the procedure. You should not drive until you feel fully recovered and it is your responsibility to ensure that you are fit to drive following your surgery.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. Your doctors will be happy to provide you with advice on request.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/or specialist one to one care is required.

Is there any research being carried out in this field at CUH?

All procedures on the prostate using the Holmium laser are subject to continuous audit within the department.

Who should I contact for more help or information?

Urology nurse practitioner (incontinence, urodynamics, catheter patients)

01223 274608 or 01223 586748 or bleep 157-237

Patient Advice and Liaison Centre (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS
Mail: PALS, Box No 53 Cambridge University Hospitals NHS Foundation Trust
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy
Mail: The Chaplaincy, Box No 105 Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know. If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

I have read this patient information leaflet and I accept the information it provides.

Signature……………………………….……………Date…………….………………….