HoLEP for large and giant prostates

Why size matters

Some of the minimally invasive treatments (UroLift, Rezum, iTind) have upper size limits. Conventional TURP becomes slower and carries more bleeding and more risk of TUR syndrome above roughly 80 grams. Historically this left open simple prostatectomy - an abdominal operation to open the bladder and shell the adenoma out by hand - as the only definitive answer for very large glands.

HoLEP has largely replaced that open operation. It uses a telescope through the urethra and a pulsed holmium:YAG laser to do the same thing - shell the adenoma out along its natural plane - without any skin incision.^{4, 10}

A note on prostate size

Prostate weight is usually estimated in grams (from trans-rectal ultrasound or MRI) or cubic centimetres (1 cc is approximately 1 g). For context:

• Normal young adult prostate: around 20 to 25 g.
• Modest BPH enlargement: 30 to 60 g.
• Large: 80 to 150 g.
• Very large: 150 to 200 g.
• Giant: over 200 g, occasionally over 500 g.

The larger the gland, the more obstructing tissue needs to be removed to restore a good urinary channel. Any operation that removes only a thin surface layer will leave most of the blockage behind.

What the evidence shows

HoLEP has been compared head-to-head with open prostatectomy in randomised trials for exactly this group of patients:

• Prostates over 70 g, 24-month follow-up. A randomised trial of HoLEP versus open simple prostatectomy showed equivalent improvements in urinary flow and symptom scores, with significantly less bleeding, shorter catheterisation and shorter hospital stay after HoLEP.⁴
• Prostates over 100 g, 5-year follow-up. A second randomised trial with a median prostate size well above 100 g confirmed that HoLEP delivered durable symptom relief out to five years, equivalent to the open operation, with the same advantages on bleeding and recovery.⁵
• Giant prostates. Published series have reported successful HoLEP in glands above 200 cc and occasionally above 500 g, with outcomes comparable to smaller prostates once the learning curve has been passed.¹⁰

A large 2025 meta-analysis of 13 randomised trials comparing HoLEP with TURP found that HoLEP removed a larger proportion of obstructing tissue and produced a lower bleeding rate, with the advantage growing as prostate size increased.⁹

Practical points for men with very large prostates

• Complete enucleation, not surface shaving. HoLEP follows the anatomical plane between the adenoma and the capsule, so the obstructing tissue is removed as whole lobes - essentially the same surgical principle as the open operation, but through the urethra.^{4, 10}
• Less bleeding. The laser seals small vessels as it cuts. Transfusion rates after HoLEP in large glands remain under 1% in most series.^{4, 5}
• No abdominal incision. Recovery, pain and catheter time are all markedly shorter than with open surgery.⁴
• TUR syndrome essentially avoided. Saline irrigation is used rather than hypotonic glycine, which means the dilutional hyponatraemia that has historically limited how long a TURP could safely be performed in a very large gland is not a concern in HoLEP cases.⁹
• Bladder stones can be treated at the same time. Long-standing obstruction often causes bladder stones, and the holmium laser can break these up during the same anaesthetic.
• Operating time is longer. Enucleating a giant prostate can take two to three hours depending on size and anatomy. This is still shorter than open surgery for most glands and does not change the hospital recovery meaningfully.⁹

Dr Kooner has been performing HoLEP for more than 20 years, and his clinical experience is consistent with the published evidence that HoLEP offers superior outcomes to TURP in large and giant prostates.