HoLEP for an enlarged prostate: what does the evidence show?

HoLEP stands for Holmium Laser Enucleation of the Prostate. It is used to treat urinary obstruction caused by benign prostatic hyperplasia, usually shortened to BPH.

The prostate sits below the bladder and surrounds the urethra—the tube through which urine leaves the body. As the inner part of the prostate enlarges, it can compress this channel and cause:

• a weak or interrupted urinary stream;
• difficulty starting urination;
• a feeling that the bladder has not emptied;
• urgency and frequency;
• getting up repeatedly at night;
• urinary retention or dependence on a catheter.

During HoLEP, the surgeon passes a telescope through the urethra. A holmium laser is used to separate the enlarged, obstructing tissue from the outer prostate along a natural anatomical plane. The released tissue is moved into the bladder, divided into smaller pieces with a morcellator and removed for laboratory analysis.

A helpful analogy is removing the flesh of an orange while leaving the peel in place. HoLEP is therefore not the same as a radical prostatectomy for prostate cancer: the entire prostate is not removed.

In most cases the operation is performed under a spinal anaesthetic with sedation: you are comfortable and drowsy rather than fully asleep, and the physiological burden is lower than with a general. A general anaesthetic is used where a spinal is unsuitable or where the patient would prefer one, and that is settled with the anaesthetist before the day of surgery.

European guidance gives HoLEP a strong recommendation as an alternative to transurethral resection of the prostate (TURP) or open prostate surgery in men who require an operation for moderate-to-severe symptoms or benign prostate obstruction.¹

Some BPH treatments cut, vaporise or compress enough tissue to create a wider central channel. HoLEP aims to remove most of the enlarged internal tissue—the adenoma—that is causing the obstruction.

This anatomical enucleation is one reason HoLEP can be effective in both conventionally sized and very large prostates. The laser also seals small blood vessels as it separates tissue, contributing to a generally favourable bleeding profile compared with traditional resection or open surgery.^{1, 3}

For most appropriately selected patients, HoLEP produces a large improvement in urinary symptoms and flow.

The International Prostate Symptom Score (IPSS) is a validated seven-question measure of urinary symptoms. It ranges from 0 to 35, with higher scores indicating more troublesome symptoms.

In a 2024 prospective registry study of 3,000 men:

• average IPSS improved from 19.3 before surgery to 6.6 at six months;
• average maximum urinary flow (Qmax) increased from 9.4 to 22.2 mL/second.

This represents an average reduction of almost 13 symptom points and more than a doubling of maximum urinary flow. Individual results vary, particularly when bladder function is impaired or urinary symptoms have more than one cause.²

Randomised trials comparing HoLEP with TURP and other laser-enucleation techniques also show substantial, sustained improvements in symptoms, flow and bladder emptying.^{3, 4, 8}

The physical blockage is removed during the operation, so many men notice a stronger stream soon after the catheter is removed. Recovery is more gradual.

During the first days or weeks, it is common to experience:

• frequency and urgency;
• burning or stinging when passing urine;
• blood in the urine;
• temporary leakage;
• increased night-time urination.

These symptoms usually settle as the prostate cavity heals. Studies commonly demonstrate clear improvement by one to three months, with further recovery thereafter. The distinction is important: the obstruction is relieved immediately, but the bladder and urinary tract need time to recover.

Durability is one of HoLEP’s principal advantages.

A randomised comparison of HoLEP and TURP reported maintained symptom and flow improvements at an average of 7.6 years. None of the 14 HoLEP patients who remained available for long-term assessment required another operation for recurrent BPH, compared with 3 of 17 in the TURP group. Because only 31 of the original 61 participants remained, this finding supports durability but does not prove that retreatment never occurs.⁴

Larger observational series provide broader, although non-randomised, long-term evidence. In 1,216 HoLEP procedures, estimated freedom from any reoperation was:

• 96.9% at five years;
• 95.1% at ten years.

These figures included later procedures for scar tissue as well as treatment for recurrent prostate obstruction.⁵

Another long-term series found that symptom, flow and quality-of-life improvements remained substantial at ten years, with repeat surgery for residual prostate tissue reported in 0.7%.⁶

A separate ten-year follow-up study reported durable symptom relief in approximately three quarters of the patients assessed. As with other extended follow-up studies, loss of participants over time and the observational design limit the precision of that estimate.⁷

The precise rate varies between studies because definitions and follow-up differ. Nevertheless, conventional HoLEP has one of the most mature durability records among modern treatments for BPH.

“Retreatment” does not always mean that the prostate has simply grown back. A further procedure may be needed for:

• residual or recurrent obstructing prostate tissue;
• a urethral stricture—scar tissue narrowing the urinary passage;
• bladder-neck contracture—scarring at the outlet of the bladder;
• another postoperative problem requiring endoscopic treatment.

In the 1,216-patient long-term series, 4.3% underwent some form of reoperation over a median follow-up of 7.6 years. This included 1.07% for residual or recurrent adenoma, 1.15% for bladder-neck contracture and 2.05% for urethral stricture.⁵

In a three-year randomised trial of men with prostates measuring 80–150 mL, repeat surgery for recurrent obstructing tissue was required in:

• 0% after HoLEP;
• 6.7% after GreenLight laser vapo-enucleation;
• 9.7% after bipolar TURP.

There were approximately 60 patients in each group, so the percentages should not be treated as universal retreatment rates. The randomised comparison nevertheless supports a low risk of recurrent obstruction after a technically complete HoLEP.⁸

Every operation carries risk. A patient’s age, health, prostate size, medication, bladder function and the surgeon’s experience all influence the individual risk profile.

Temporary urinary leakage

Some men experience leakage after HoLEP, particularly with coughing, standing or activity. It is usually temporary and improves as the urinary sphincter recovers.

In the 3,000-patient prospective study, stress urinary incontinence was reported in 1.9% and urgency incontinence in 1.3% at six months.² Other studies report higher rates, especially when they include very mild leakage or assess patients earlier after surgery. Surgeon experience and differences in technique and definitions help explain this variation.¹

Persistent troublesome incontinence is uncommon, but it cannot be guaranteed not to occur.

Bleeding

Bleeding can occur during or after any prostate operation. Systematic reviews of randomised trials generally find less blood loss and a lower transfusion risk with HoLEP than with TURP. HoLEP also tends to involve shorter catheterisation and hospital stay, although operating time may be longer.³

Burning, urgency and frequency

Temporary burning and “irritative” urinary symptoms are common while the surgical cavity heals. A meta-analysis found postoperative dysuria—pain or burning when passing urine—to be more frequent after HoLEP than after TURP, despite HoLEP’s advantages for several other perioperative outcomes.³

Scar tissue

A urethral stricture or bladder-neck contracture can reduce the urinary flow again and may require another endoscopic procedure. In the large prospective cohort, urethral stricture occurred in approximately 1.0% and bladder-neck contracture requiring treatment in approximately 0.5% by six months.²

Infection and other risks

Urinary infection, difficulty passing urine after catheter removal, clot retention, anaesthetic complications and the need for an unplanned further procedure are possible. The exact risk should be discussed in the context of the patient’s health and planned operation.

Erections and ejaculation are different functions and should be discussed separately.

Randomised comparisons and guideline reviews are broadly reassuring that HoLEP does not usually cause a lasting deterioration in erectile function. Some men may notice a temporary change during recovery; erections may also be influenced by age, vascular health, medication and erectile function before surgery.^{1, 4}

No operation can guarantee unchanged erectile function, but loss of erections is not the expected sexual consequence of HoLEP.

Conventional HoLEP commonly causes loss of forward—or antegrade—ejaculation. Semen may no longer emerge from the penis during orgasm, or the volume may be greatly reduced. The sensation of orgasm and the ability to achieve an erection can remain normal.

Patients considering conventional HoLEP should regard a dry or markedly reduced-volume orgasm as likely rather than unusual.

In a recent prospective—but non-randomised—comparison, ejaculatory dysfunction at six months was reported in 89.3% after HoLEP and 6.6% after Aquablation. The study involved 150 patients and should not be used as a universal estimate, but it illustrates the recognised difference between conventional HoLEP and treatments designed specifically to preserve ejaculation.⁹

Potentially. Several ejaculation-preserving HoLEP techniques aim to retain selected tissue around structures involved in ejaculation.

A 2026 systematic review included 10 studies and 1,675 patients, comprising three randomised trials, four non-randomised comparative studies and three single-arm series. More comprehensive anatomical preservation techniques reported forward-ejaculation preservation rates of approximately 70–85% in selected patients, while short-term symptom and flow improvements appeared broadly comparable with conventional HoLEP.¹⁰

These findings are promising, but the techniques are not yet standardised. Patient selection, surgical method and outcome definitions vary, and long-term durability is less certain than for conventional HoLEP. Leaving tissue to protect ejaculation may also involve a trade-off between preservation and the completeness of obstruction relief.

If ejaculation is a priority, useful questions include:

• Which preservation technique is being proposed?
• Is my prostate anatomy suitable?
• What proportion of the surgeon’s own patients retain forward ejaculation?
• Could tissue preservation affect symptom relief or future retreatment?
• How long have patients undergoing this specific technique been followed?

HoLEP is widely described as size-independent because the same principle can be applied across a broad range of prostate volumes. It can treat a prominent median lobe and is particularly valuable for large or very large prostates that may otherwise require open or robotic simple prostatectomy.¹

In an experienced-centre series of 88 men with prostates of at least 200 mL, the average size was approximately 256 mL and the largest was 770 mL. Average hospital stay was 1.8 days and catheterisation 2.6 days; one patient required BPH retreatment during the reported follow-up. This was an observational study, so it demonstrates feasibility in expert hands rather than proving that HoLEP is the best option for every exceptionally large prostate.¹¹

Size-independent does not mean anatomy-independent. The shape of the prostate, median-lobe enlargement, previous procedures, bladder-neck anatomy, urinary retention and bladder function can all affect treatment planning. A very small obstructing prostate may sometimes be better treated by another procedure, depending on the cause of the obstruction.

Longstanding obstruction can be associated with detrusor underactivity, meaning the bladder muscle contracts less strongly. Removing the obstruction cannot guarantee restoration of a weakened bladder, but many patients still benefit.

In a 2024 observational study of 689 patients—including 364 with detrusor underactivity—both groups experienced significant improvements in symptoms, flow and residual urine after HoLEP. At six months, reported satisfaction was 90.5% in men with detrusor underactivity and 95.2% in those with normal contractility. The weaker-bladder group had somewhat lower flow and slightly greater residual symptoms after surgery.¹²

In selected patients, bladder testing may help distinguish obstruction from impaired bladder contraction before surgery.

There is no single best BPH procedure for every patient. The balance depends on prostate anatomy, degree of obstruction, general health, recovery preferences, sexual priorities and willingness to accept future retreatment.

HoLEP or TURP?

TURP remains an effective, established operation. Compared with TURP, randomised evidence generally finds that HoLEP offers:

• at least comparable symptom and flow improvement;
• less bleeding and lower transfusion risk;
• shorter catheterisation and hospital stay;
• strong long-term durability;
• but often a longer operating time.

Both commonly affect ejaculation.^{3, 4}

HoLEP or Aquablation?

Aquablation uses a robotically controlled high-pressure water jet. Early comparative evidence suggests that both treatments can produce major symptom and flow improvements, while Aquablation is more likely to preserve ejaculation. HoLEP has the more mature evidence base for complete tissue removal and long-term durability. Direct comparative evidence remains relatively limited and includes non-randomised studies.⁹

HoLEP or Rezūm?

Rezūm uses water vapour to treat selected prostate tissue. It is less invasive and more likely to preserve ejaculation, but improvement is slower, less tissue is removed and retreatment is more likely than after anatomical enucleation.

A 2025 matched observational comparison found better 12-month symptom scores, flow and bladder emptying after HoLEP, while ejaculation favoured Rezūm. Because the study was not randomised, it is supportive rather than definitive evidence.¹³

HoLEP or GreenLight laser?

Both can improve urinary symptoms. In the randomised study of 80–150 mL prostates, symptom outcomes were comparable at three years, but repeat surgery for recurrent obstructing tissue occurred more often after GreenLight vapo-enucleation than after HoLEP. Results may vary with the GreenLight technique and technology used.⁸

HoLEP or thulium laser enucleation?

HoLEP, ThuLEP and ThuFLEP all use the same central principle: anatomical enucleation of the obstructing prostate tissue. Randomised trials generally show large and broadly comparable improvements. The surgeon’s training and experience may be more important than small technical differences between modern laser platforms.

HoLEP or robotic simple prostatectomy?

Both can provide substantial relief for very large prostates. Systematic reviews—based mainly on observational rather than randomised evidence—find broadly similar functional results, while HoLEP is generally associated with shorter hospitalisation and catheterisation and a lower transfusion risk. Robotic surgery may still be appropriate in selected patients, particularly when another condition requires an abdominal or robotic approach.¹⁴

HoLEP may be worth considering for a patient who has:

• moderate or severe urinary symptoms despite medication;
• clear bladder-outlet obstruction from an enlarged prostate;
• recurrent urinary retention or catheter dependence;
• a large or very large prostate;
• bladder stones, recurrent infection or other consequences of obstruction;
• recurrent obstruction after a previous BPH procedure;
• a strong preference for a treatment with established long-term durability.

It may be less attractive when preservation of forward ejaculation is the overriding priority, although an ejaculation-preserving modification might be possible in selected anatomy. Symptoms caused mainly by an overactive or poorly contracting bladder may also not resolve fully simply by removing prostate obstruction.

The evidence should be interpreted according to the question being asked:

This distinction matters. Results from a newer ejaculation-preserving modification should not automatically be assumed to have the same ten-year evidence as a conventional, complete HoLEP.

HoLEP is one of the best-supported surgical treatments for benign prostate enlargement. It can provide a large improvement in urinary symptoms, a substantial increase in urinary flow and a low likelihood of needing repeat surgery for recurrent obstruction. It is applicable across a particularly wide range of prostate sizes and has long-term evidence extending beyond ten years.

The trade-offs remain important. Recovery can involve temporary urgency, burning, bleeding and leakage. Conventional HoLEP usually results in loss of normal forward ejaculation, although erections are generally preserved. Ejaculation-preserving techniques are developing rapidly but do not yet have the same standardisation or depth of long-term evidence.

The right choice depends not only on prostate size, but also on anatomy, bladder function, general health, medication, the importance of preserving ejaculation and the patient’s attitude to durability and possible retreatment. A specialist assessment should bring these factors together in a shared decision.