Benign Prostatic Hyperplasia (BPH), and My Journey with HoLEP by Dr Santosh Bugwandin

We spoke with Dr Santosh Bugwandin recently, who is a specialist urologist based in Pietermaritzburg, about his journey with a new minimally invasive surgical option for treating Benign Prostatic Hyperplasia (BPH) that he pioneered in South Africa. Dr Bugwandin holds a Fellowship from the College of Urologists of South Africa: FCUrol(SA) and has developed his expertise in urology through local and international courses. He is a national expert in Holmium Laser Enucleation of the Prostate (HoLEP) and is one of the proctors/trainers for the procedure in South Africa.

The treatment of Benign Prostatic Hyperplasia (BPH) encompasses lifestyle changes, medical therapy, minimally invasive therapies and surgery. For several decades TURP has been the gold standard in BPH surgery, with Open Prostatectomy for large glands, but this is now changing with a day-surgery procedure, namely HoLEP, which is the favoured therapy in the UK, Europe and USA.

HoLEP refers to Holmium Laser Enucleation of the Prostate, where a cystoscope is passed through the urethra, and the prostate is ‘shelled out’ from its capsule, using laser energy, and dropped into the bladder. It is then broken down and sucked out with a morcellator with minimal bleeding. This procedure is the first surgical option that has matched and superseded TURP and Open Prostatectomy in the short and long term. At a recent EAU Congress, it was hinted that HoLEP will be named the new gold standard once a sufficient number of training centers are established.

HoLEP is a minimally invasive technique that allows for removal of glands of any size, thus eliminating the need for open surgery and TURP. It is a faster procedure, that has fewer intraoperative and post operative side effects. It can be performed as a day case, saving costs for all parties, while allowing the urologist to avoid post-op ward visits. The patient benefits from the lower morbidity, cost and time off his feet.

I choose HoLEP due to the mountain of evidence and several guidelines supporting its use, and also because I have seen the patient satisfaction first-hand.

As a surgeon, I find HoLEP to be an elegant procedure that follows basic surgical principles. It also saves me time - with a shorter OT time, fewer complications and shorter post operative time.

My journey in HoLEP began in 2013 when I watched Dr Mark Cynk perform a HoLEP at Greys Hospital in Pietermaritzburg. I had a chance to enucleate a small prostate at that time as well. Having been convinced of the Holmium lasers utility, I began to use the laser for minor tissue surgery. I then attended a Masterclass in Laser Principles and HoLEP in November 2014. This was held at the Cleveland Clinic run Sheik Khalifa Medical City in the UAE, under the auspices of the UK Holmium Users Group.

I returned to South Africa and used makeshift resection equipment to perform partial HoLEPs, while battling the lack of proper enucleation equipment and funding restrictions. In late 2017, a colleague and myself met with senior hospital management in KZN and secured the correct equipment required. HoLEP began to enter our daily practices in 2018, with funders  finally allowing for HoLEP authorization. I have not Voluntarily performed a TURP since early 2019.

My surgical treatment of BPH has evolved from TURPs involving a three day hospital stay with bloody urine and bladder irrigation, to HoLEP day-surgery with negligible post-op bleeding. I have recently discharged a patient within 3 hours of completing a HoLEP.

I now fill a HoLEP proctorship role, regularly advising and training other urologists who are keen on learning HoLEP. I have always been a proponent of high powered lasers, and I utilise a high powered laser for all my HoLEP surgery at present.

HoLEP is due to replace TURP and Open Prostatectomy in guidelines around the world in the same way that laparoscopic and robotic surgery has replaced open procedures. It is in the interest of urologists and their patients to introduce HoLEP into all our daily practices.