Holmium Laser Enucleation of the Prostate (HoLEP)

At a glance

• What it is: A transurethral operation that removes the obstructing inner portion of the prostate using a holmium:YAG laser, with no external incision.^{2, 10}
• Who it suits: Men with symptomatic benign prostatic hyperplasia (BPH), from modest enlargement through to very large and giant glands over 200 cc.^{1, 4, 5}
• Appropriate for men on blood thinners: International guidance identifies HoLEP as an appropriate option at higher bleeding risk, including those on anticoagulant or antiplatelet therapy.^{1, 11, 12, 18}
• Durable: Randomised and long-term cohort data show symptom relief maintained out to 7 to 10 years, with approximately 95% of men free of any repeat prostate operation at ten years.^{3, 6, 8}
• Lower bleeding rate: Meta-analyses of randomised trials consistently show less bleeding than with standard transurethral resection of the prostate (TURP).^{9, 11}
• Short hospital stay.^{4, 9}

What is HoLEP?

Holmium Laser Enucleation of the Prostate (HoLEP) is a transurethral operation for an enlarged prostate. A holmium:YAG laser is used to separate the obstructing inner portion of the prostate (the adenoma) from its outer capsule in whole lobes. The tissue is then pushed into the bladder and broken down with a mechanical morcellator, or left on a small stalk and removed (the "mushroom technique").¹⁹ It is then removed through the urethra.^{2, 10} There is no cut on the abdomen or anywhere on the skin.

Because the operation follows the natural anatomical plane between the adenoma and the capsule, HoLEP removes proportionally more obstructing tissue than a conventional TURP, which shaves the prostate from the inside rather than enucleating it.^{4, 9}

Who is suitable for HoLEP?

HoLEP is described in international guidance as effectively independent of prostate volume - it remains a valid option across the full range of gland sizes.^{1, 4, 5} It is especially often recommended for:

• Men with moderate to severe lower urinary tract symptoms due to BPH that have not responded adequately to medication.¹
• Men with large or very large prostates, including glands over 100 g and giant glands over 200 cc, where some alternative procedures are limited by size.^{1, 4, 5} See HoLEP for large and giant prostates.
• Men taking anticoagulant or antiplatelet therapy.^{1, 11, 12, 18} See HoLEP for men on blood thinners.
• Men in urinary retention or dependent on an indwelling or intermittent catheter because of prostatic obstruction.^{6, 16}
• Men with bladder stones or a bladder diverticulum caused by long-standing obstruction. The holmium laser can fragment bladder stones during the same anaesthetic.

The full range of BPH procedures is available, which allows the recommendation to be matched to the individual patient rather than the other way round. See the alternatives hub for short summaries of the non-laser options.

How is HoLEP performed?

HoLEP is performed under general or spinal anaesthesia and typically takes between 60 and 150 minutes depending on prostate size.^{4, 5} The procedure runs as follows:

1. Telescope through the urethra. A resectoscope is passed along the urethra into the prostate. There is no external incision.
2. Laser enucleation. A holmium:YAG laser fibre, pulsed at a wavelength of approximately 2,100 nm, develops the plane between the adenoma and the surgical capsule.² This is the same anatomical plane a surgeon's finger would follow during an open simple prostatectomy.⁴
3. Lobes freed. The obstructing lobes of the prostate - typically a median lobe and two lateral lobes - are freed as whole pieces.¹⁰
4. Morcellation or mushroom removal. The prostate segment can be left with a small attachment and then removed piecemeal through the urethra. Alternatively it is pushed into the bladder and morcellated through the resectoscope.
5. Pathology. The detached tissue fragments are sent for routine histological examination.¹⁰
6. Catheter. A urinary catheter is placed at the end of the operation to drain the bladder and flush any blood-stained urine while the prostatic fossa heals. It is usually removed within one to a few days.^{4, 9}

Irrigation is with normal saline, the same isotonic fluid used in intravenous drips. Unlike the hypotonic glycine irrigation used historically with monopolar TURP, saline absorption is not clinically significant, so TUR syndrome (dilutional hyponatraemia) is not a meaningful risk with HoLEP.⁹

HoLEP vs TURP

Compared with standard TURP, pooled randomised data and large series report that HoLEP offers:

• Less bleeding and fewer transfusions. Transfusion rates after HoLEP are typically under 1% in large series, significantly lower than after TURP.^{9, 11}
• Shorter catheterisation.^{4, 9}
• Shorter hospital stay. Roughly two to three days on average for HoLEP, shorter than TURP in most trials.^{4, 9}
• More obstructing tissue removed. Because HoLEP enucleates the adenoma rather than shaving it, a larger volume of obstructing tissue is removed for a given gland size.^{4, 9}
• A lower rate of repeat surgery. In a recent national registry of more than 33,000 primary surgical interventions, 97% of HoLEP patients had not required a further prostate operation at three years, compared with 93.5% after TURP.¹⁷
• No meaningful risk of TUR syndrome. Saline irrigation eliminates the dilutional hyponatraemia that has historically been a rare but serious concern with monopolar TURP.⁹

The usual trade-off is a slightly longer operating time for HoLEP than for a comparable TURP, which is not generally of clinical consequence to a patient.⁹

Advantages of HoLEP

• Size-independent. HoLEP can be offered across the full range of prostate sizes.^{1, 4, 5}
• Minimally invasive. The procedure is entirely transurethral, with no skin incision.²
• Saline irrigation. Eliminates the metabolic risk of TUR syndrome associated with older hypotonic-glycine TURP.⁹
• Haemostatic. The laser seals small vessels as it cuts, independent of the patient's own clotting status. That is why HoLEP can be offered safely to men on anticoagulant or antiplatelet therapy.^{11, 12, 18}
• Tissue preserved for pathology. The fragments are sent for routine histological examination, which can incidentally detect occult prostate cancer in a small proportion of cases.¹⁰
• Durable. Long-term cohort and randomised evidence show maintained symptom relief at 7 to 10 years with low reoperation rates.^{3, 6, 8}

Risks and complications

Every patient is counselled on the following before surgery. Published rates from contemporary series are included for context.

• Retrograde ejaculation. Most men (approximately 70 to 80%) will have reduced or absent antegrade ejaculate afterwards; semen passes back into the bladder. Orgasm sensation is generally preserved. Natural conception without assisted reproduction is not reliably possible afterwards, which should be raised in advance by men who still wish to father children.¹⁵
• Erectile function. Long-term cohort data and a 2024 narrative review report no significant deterioration in validated erectile function scores at 12 months and beyond.¹⁵
• Bleeding and transfusion. Transfusion after HoLEP is very uncommon and is lower than after TURP in pooled randomised evidence.^{9, 11} In men on anticoagulants, the rate is modestly higher but return to theatre for bleeding is still rare.^{11, 12, 18}
• Bladder neck contracture or urethral stricture. Scar-tissue narrowing occurs in roughly 2 to 5% of cases over long-term follow-up and is usually managed with a small endoscopic day-procedure.^{7, 8}
• Lower urinary tract irritation. Frequency, urgency and mild burning on passing urine are common in the first few weeks. Blood-tinged urine can briefly recur around 10 to 14 days after surgery when a healing scab separates.
• Transient stress incontinence. A minority of men experience some leakage with effort in the first few weeks. This tends to improve with early pelvic-floor exercises.^{13, 14}
• Repeat prostate surgery. Uncommon - 95% of men had not required any further prostate operation at ten years in a single-centre series of more than 1,000 procedures.⁸

How durable are the results?

HoLEP has one of the strongest long-term evidence bases of any surgical BPH treatment.

• In a randomised trial with follow-up approaching eight years, none of the HoLEP patients remaining in the analysis had required reoperation for BPH.³
• In a 10-year follow-up cohort, approximately three quarters of men remained free of clinically significant symptoms at that interval.⁶
• In a single-centre series of more than 1,000 HoLEP procedures, Kaplan-Meier freedom from any repeat prostate surgery was 95% at ten years.⁸

For most men, HoLEP will be the only prostate operation they ever need.

Why HoLEP is not offered everywhere

• Substantial learning curve. Published learning-curve analyses suggest that technical efficiency and continence outcomes improve steadily over the first 20 to 50 cases, and reoperation rates are lower at high-volume centres.^{7, 17}
• Capital cost. A high-powered holmium laser platform is expensive, and not every hospital has one available.

Surgeon and hospital experience matter. Dr Kooner has been performing HoLEP for more than 20 years and has completed over 3,000 cases at St Vincent's Private and Mater Hospital North Sydney.

Recovery summary

The full week-by-week recovery guide sits on its own page. In outline:

• Hospital: one to three nights, catheter usually removed the next morning.^{4, 9}
• First two weeks: mild burning on passing urine, occasional pink urine, urgency. Walking from day one; avoid heavy lifting, cycling and straining.
• Two to six weeks: flow continues to improve; return to physical work and exercise from about four weeks.⁹
• Three to six months: most of the urinary benefit is in. Nocturia typically takes the longest to settle.
• Six-week review with flow study, bladder scan, IPSS and pathology report.