Holmium Laser Incision of the Bladder Neck (HoLBNI)

What HoLBNI is

A cystoscope is passed along the urethra. A holmium:YAG laser fibre, pulsed at approximately 2,100 nm, is used to make one or two incisions through the bladder neck muscle at the 5 and 7 o'clock positions. The cuts release the tight ring of tissue, so the bladder empties more easily. Unlike HoLEP, tissue is not removed in volume; the procedure opens the channel rather than enucleating the adenoma.

HoLBNI is effectively the laser equivalent of the long-established "bladder neck incision" that is also performed with an electrosurgical Collings knife. Because the laser coagulates as it cuts, bleeding tends to be minimal.

Who HoLBNI suits

• Men with a small prostate (often under 30 cc) and a tight, narrow bladder neck that is the main source of obstruction.
• Men with recurrent obstruction after previous prostate surgery (TURP, HoLEP, GreenLight) where the adenoma has been cleared and only a bladder-neck scar remains.
• Men with bladder-neck hypertrophy (primary bladder-neck obstruction), sometimes seen in younger men with a long history of poor flow and a normal-sized prostate.

Advantages

• Short procedure. Often 10 to 20 minutes of laser time.
• Day surgery. Most men go home the same day or the following morning.
• Preservation of antegrade ejaculation in some cases. Because the incision is targeted and does not strip out the internal sphincter in the way enucleation does, a proportion of men retain antegrade ejaculation. This is more likely if a single unilateral incision is used; results are discussed case by case.
• Minimal bleeding. The holmium laser is haemostatic.

Limitations

• HoLBNI does not treat a bulky adenoma. If the obstruction is mainly from lateral-lobe enlargement or a significant median lobe, a full enucleation (HoLEP) or vaporisation (GreenLight) is needed.
• Symptom relief depends on the bladder neck being the dominant source of obstruction. A pre-operative flexible cystoscopy is important to confirm this.
• In occasional cases a second procedure (often a short HoLEP) is needed later if tissue regrowth or a second area of obstruction becomes symptomatic.

Recovery

• Catheter is removed within 24 hours in most cases.
• First week - some irritative urinary symptoms; occasional mild blood-tinged urine. Drink extra fluid and rest.
• Return to work within a few days for office work. Heavy lifting, cycling and strenuous exercise delayed for 2-3 weeks.
• Follow-up with a flow study and bladder scan at around 6 weeks.