Hybrid BPH Treatment - Laser and UroLift

About this hybrid approach

In selected men, an enlarged prostate can be treated with a combination of laser prostate treatment and UroLift implants in the same procedure. The aim is to relieve obstruction while preserving as much of the surrounding anatomy as possible. Whether this combination is appropriate depends on prostate size and shape, urinary symptoms, fitness for surgery, and personal priorities.

Who the hybrid approach may suit

The combination is considered for men whose obstruction comes from more than one part of the prostate at the same time: an enlarged or prolapsing median lobe (middle lobe) sitting into the bladder outlet and causing the dominant blockage, together with lateral lobes (side lobes) that are also contributing some degree of obstruction.

That pattern is difficult to treat well with a single technique. UroLift alone is designed primarily for lateral-lobe obstruction, and a large obstructing median lobe often needs tissue removed rather than held aside. A tissue-removing operation treats the whole prostate, but carries a higher rate of retrograde ejaculation. The hybrid approach is a way of matching each technique to the part of the prostate it treats best.

How the procedure is performed

Both parts are carried out in the one operation, through the urethra, with no external incision:

1. The median lobe is enucleated with the holmium laser. The obstructing or prolapsing middle lobe is separated from the prostate capsule and removed, in the same way as a holmium laser enucleation of the prostate (HoLEP), clearing the tissue that is blocking the bladder outlet.
2. The lateral lobes are then treated with the UroLift device. Small permanent UroLift implants are placed to hold the side lobes apart rather than removing them, opening the remainder of the channel mechanically.

The intention is a clear channel through the prostate, with tissue removed only where removal is necessary.

Hospital stay and recovery

Men are usually kept in hospital for one to two nights with a catheter in position. Improvement in the urinary stream is usually noticed relatively quickly once the catheter is removed. As with any prostate operation, some urinary frequency, urgency, burning on passing urine and light bleeding are expected in the early weeks while the prostate settles, and a follow-up review is arranged in the rooms.

Ejaculatory function and other risks

The reason the combination is used is to reduce the chance of retrograde ejaculation (semen passing backwards into the bladder rather than forwards) compared with removing all of the obstructing tissue, while still achieving a worthwhile improvement in urinary flow. It reduces that risk; it does not remove it.

Dr Kooner currently quotes men a risk of retrograde ejaculation in the order of 20 to 25% after the hybrid procedure. The practice is analysing its own results so that this figure can be given to patients more precisely.

The other risks are those of the two component procedures, and are discussed in full before surgery. They include bleeding and blood in the urine, urinary infection, temporary urgency, frequency or discomfort on passing urine, temporary difficulty passing urine requiring a further period of catheterisation, the small possibility of implant-related problems such as displacement or encrustation, the possibility of needing a further prostate procedure in the future, and the general risks of anaesthesia. Detailed risk information for each component is on the holmium laser and UroLift pages.

The hybrid approach at Urology NSW

Dr Raji Kooner has performed approximately 40 hybrid procedures combining holmium laser enucleation of the median lobe with UroLift implants to the lateral lobes. The approach uses two established minimally invasive techniques together in the one anaesthetic, with the aim of a rapid improvement in urinary symptoms.

The hybrid approach sits alongside the practice's other treatments for an enlarged prostate: holmium laser enucleation (HoLEP), UroLift, Rezum water vapour therapy, iTind and transurethral resection of the prostate (TURP). A comparison of every option is on the BPH treatment options page, and the other minimally invasive options are summarised on the minimally invasive treatments page.

Whether the hybrid approach is appropriate in any individual case depends on the prostate size and shape, the pattern of obstruction found on assessment and cystoscopy, urinary flow studies, fitness for anaesthesia, and the patient's own priorities. Men who would like to discuss whether this approach suits their situation are welcome to request a second opinion or to telephone the rooms to arrange a consultation.