Minimally invasive HoLEP procedure, considered the gold-standard surgery for enlarged prostate, is unavailable in California. So, despite the pandemic, John Steinberg flew to Philadelphia.
An enlarged prostate, also known as benign prostatic hyperplasia (BPH), is quite common in older men. As the prostate grows, it may push against the bladder or close around the urethra. This can cause problems with urination. Urinary problems due to an enlarged prostate should not be considered a normal sign of aging, though. Men should seek treatment; without it, an enlarged prostate may interfere with a normal lifestyle, and sometimes can cause severe bladder or kidney damage.
Unfortunately, the availability of holmium laser enucleation of the prostate (HoLEP), a minimally invasive procedure for BPH developed during the 1990s in New Zealand, is quite uncommon in the United States. HoLEP replicates an open prostatectomy procedure without an incision for treatment of an enlarged prostate. Many clinical trials have shown HoLEP, which uses a laser to remove tissue blocking urine flow through the prostate, to be more effective and durable than open prostatectomy or minimally invasive transurethral resection of the prostate (TURP). HoLEP also results in less catheter time, shorter hospital stays, less risk of blood transfusion and quicker recovery.
Fortunately, HoLEP is available at Thomas Jefferson University Hospital in Philadelphia. The procedure is performed by urologist Dr. Akhil K. Das, who learned it from one of its developers as a Fellow at Tauranga Hospital in New Zealand. And that’s what led 69-year-old John Steinberg to fly across the country from California, where HoLEP is unavailable, to see Dr. Das in August. This, despite the pandemic.
In order to be closer to their daughter and grandson, John and his wife, Laurie, retired to Upland, California, three years ago after he spent 37 years working for the Forestry Division of the Department of Environmental Services in Rochester, NY. For several years, when John underwent annual exams, he was made aware of his enlarged prostate. But because it wasn’t causing him any discomfort, he did nothing about it. He was otherwise in good shape.
In July 2018, however, following retirement, John had his gallbladder removed. After his discharge, he ended up in the emergency room. He was catheterized because of severe urinary retention, due to the impact general anesthesia had on his prostate.
“Altogether, I had been catheterized five times over two years,” says John. “One especially bad time was when I was unable to urinate during a flight to New York and had to rush to an ER as soon as I arrived.”
Not Much Medical Help
It’s not as though John didn’t try to get help over the past two years. In fact, he saw two different urologists, but neither was much help in shedding light on the problem. One urologist revealed that John’s bladder was infected, and an MRI showed no signs of prostate cancer. Unfortunately, John also found out that his prostate had swelled to 197 cc. For perspective, a healthy prostate is between 25 and 30 cc.
“This past July,” he says, “I underwent general anesthesia again—this time, for hand surgery. Following discharge from the hospital, I had to go to the ER yet again, during the pandemic, to be catheterized and then, due to an infection, re-catheterized because I was still retaining a dangerous amount of urine and had a serious bladder infection. That was the final kicker for me. At that point, I at least knew my prostate was seriously enlarged but had been given no decent guidance from any doctor about a suitable treatment option.”
A Leap of Faith
Frustrated, John finally got some valuable medical advice—but not from a urologist. His nephew, a cardiac thoracic surgeon in Indiana, told John he had successfully undergone the HoLEP procedure, performed by a urologist who had studied under one of its developers in New Zealand. That urologist was unable to see John for a few months, so John and his wife, Laurie, searched the internet for other physicians who did the HoLEP procedure. They struck gold when they found Jefferson’s Dr. Das. They phoned his office and learned that Dr. Das could see them in just three weeks. They immediately booked a flight for August 3.
“We felt that the circumstances warranted that,” says John. “Despite COVID-19, we had to take the risk and a leap of faith because my infection was only getting worse. But we took all possible precautions to fly safely from California to Philadelphia. Fortunately, there were no problems—our entire trip was as smooth as silk.”
Making a Great First Impression
Early the next morning, August 4, John and Laurie met with Dr. Das. “Beginning with his receptionist, everyone was so nice,” John enthuses. “Dr. Das was super friendly and put us at ease immediately. He reviewed my history thoroughly, asking many questions, answered all of our questions, and patiently and confidently concluded that he could help me with my BPH. We were especially happy to learn that he had studied the HoLEP procedure from its inventor, Dr. Peter Gilling, while he was in New Zealand, just as my nephew’s urologist in Indiana had. That, along with his vast experience and great bedside manner, greatly comforted Laurie and me.”
Dr. Gilling was the first to describe the HoLEP technique in 1997, during which time Dr. Das was learning the technique from him as a Fellow in Tauranga, New Zealand. In 1998, Dr. Das was one of the first physicians to perform HoLEP in the U.S. and has continued to improve the technique and equipment involved since. The most recent guidelines published by the American Urologic Association note that the HoLEP technique offers superior outcomes and is one of the most thoroughly studied procedures for BPH. It can be used for prostates of any size and in patients taking blood thinners. These specific attributes and benefits of HoLEP procedure have made it the “gold standard.”
Before John and Laurie left the office on the first day, Dr. Das’ administrator, Cindy Caruso, walked them through everything, including where they had to go and when, and helped John sign up for Jefferson’s electronic patient record system, MyChart, so he had handy online access to all of this information on his smartphone. “We thought that was fantastic,” says John. Over the next few days, John underwent a number of necessary preoperative procedures.
A Successful Outcome
On August 10, Dr. Das performed the HoLEP procedure on John. It took three and one-half hours, after which John spent the night resting comfortably in the recovery room at Thomas Jefferson University Hospital. “My night nurse fussed over me like it was nobody’s business,” he enthuses.
John was discharged the following morning, but, on the advice of Dr. Das, stayed at the hotel for three more days to recuperate and ensure he experienced no complications from the surgery. Dr. Das conducted one more evaluation and told John all was well. The following Monday—one week after his surgery—John and Laurie took another uneventful flight home, feeling much more comfortable and very relieved.
A Great Patient Experience
“I’m feeling great!” declares John two months after surgery. “Every day has been an improvement. A side effect of the procedure is temporary incontinence, which is normal. It typically clears up in a number of weeks, and every day has been better and better. I’m almost 100 percent back to normal. I’m back to riding my bike 10 miles a day and living as normal a lifestyle as one can these days.
“Jefferson provided me with a great patient experience and I got my life back. They really took all the worry out of my surgery. Laurie and I knew we were in the hands of people who really care about their patients. We just can’t thank them enough.”