HoLEP for urinary retention

Two patterns of retention

• Acute urinary retention. Sudden, painful inability to pass urine, usually requiring a catheter in the emergency department. A trial of void with an alpha-blocker succeeds on the first attempt in roughly two-thirds of cases, but the long-term risk of a further retention episode - and of bladder damage - is high, so surgery is usually planned.
• Chronic urinary retention. A gradually enlarging bladder with a very large post-void residual, sometimes more than a litre. Often painless and picked up on imaging or during assessment of weak flow. Can be high-pressure (risking kidney function) or low-pressure (with an overdistended, underactive bladder).

Why HoLEP is a strong option

• Complete clearance. HoLEP removes the obstructing adenoma rather than shaving it from the inside, so the channel through the prostate is reliably opened even in large glands.^{4, 5}
• Size independence. Retention is more common with larger prostates. HoLEP has no meaningful upper size limit.^{1, 4, 5}
• Reliable catheter removal. Published series including men in retention before surgery show high rates of successful voiding after HoLEP, and freedom from re-catheterisation at mid-term follow-up.¹⁶

Bladder function matters

Men who have been catheter-dependent for a long time can develop a weak (underactive) bladder. In most cases, the bladder muscle recovers function gradually after the obstruction is cleared, but this is not guaranteed. Pre-operative assessment (a focused urodynamic study in selected cases) helps establish what to expect.

Where the bladder is thought to be predominantly underactive rather than obstructed, HoLEP still often improves voiding because even a small residual obstruction is significant in a weak bladder. Some men may need intermittent self-catheterisation for a period afterwards while the bladder muscle recovers.

Timing of surgery

Most men with an episode of acute retention proceed to HoLEP within a few weeks once the bladder has settled and any associated urinary infection has cleared. Men with chronic high-pressure retention with kidney involvement are managed first with a catheter to decompress the system, and then proceed to HoLEP once the creatinine has stabilised and any salt-wasting diuresis has resolved.