HoLEP | Dr. Petronio Melo

Quick answer

HoLEP is holmium laser enucleation of the prostate. The surgery is done through the urethra, with no cuts in the skin, and removes the tissue that blocks the flow of urine. The European guideline recommends it as an alternative to TURP and open surgery.¹ Compared with TURP, it had fewer transfusions, shorter catheter time and hospital stay, and a longer operation.^1,2

How it is done

AccessAn instrument goes in through the urethra, with no cuts in the skin.
LaserThe laser separates the obstructing tissue from the capsule and controls bleeding.¹
RemovalThe freed tissue goes into the bladder, where it is broken up and removed through the instrument.
Catheter and dischargeYou leave surgery with a catheter in the bladder. In my practice, it comes out before discharge, and the hospital stay is usually under 24 hours.

The holmium laser is absorbed by the water in the tissue, so it acts on the surface, with 3 to 4 mm of coagulation.¹ The surgeon's experience is the factor that weighs most on complications.¹

Schematic animation of HoLEP. The instrument is not shown in the drawing.

Who it is for

The European guideline recommends HoLEP for men with moderate or severe symptoms caused by obstruction, as an alternative to TURP and open surgery.¹ HoLEP is possible even in men who take blood thinners. Laser enucleation has been done safely in men on anticoagulants or antiplatelet drugs, although randomized studies in this group are still lacking.¹

In four randomized studies against open surgery in large prostates, relief was similar. Open surgery had longer catheter time and hospital stay and more transfusions, while HoLEP took longer to perform.¹ The guideline's recommendation does not name a weight limit.¹ In practice, this has to be assessed case by case.

What the studies show

Source	Patients	Result
Canadian series, 2011	949 men	IPSS from 19 before to 3.8 at ten years⁵
Review, 2014	855 men, against TURP	Fewer transfusions; catheter about 20 hours and hospital stay about 25 hours shorter²
Review, 2025	Average follow-up of 7.3 years	Second operation in 4.1% of cases, on average⁴

Over the medium and long term, HoLEP worked about as well as TURP in the European guideline.¹ The 2011 series comes from a single center, and long-term studies lose some patients along the way.^4,5

Risks

Review of 57 studies, 10,371 operations	Frequency
Temporary urine leakage	7%
Blood in the urine with clots	2.6%
Narrowing of the urethra	2%
Permanent urine leakage	1.3%
Narrowing of the bladder neck	1%

Burning on urination occurred in 7.5%.³ The most common complications around the time of surgery were not serious.³

Erections and ejaculation

The effect on erections was comparable to other techniques in the European guideline. In a review of randomized studies, scores were slightly higher after enucleation than after TURP in the long term.^1,6

In retrograde ejaculation, semen goes into the bladder. It is very common with the conventional techniques, such as TURP, Greenlight and HoLEP, and the rates after HoLEP were similar to TURP.^1,6 In my practice, HoLEP almost never preserves ejaculation.

If preserving it matters to you, you can consider Rezum, the water vapor treatment. It tends to preserve ejaculation in 80% to 90% of cases.^7,8 In the randomized Rezum study, an analysis done after the trial showed no clinically relevant change in ejaculation at 5 years.⁹ If this matters to you, we talk it through before choosing the technique.

How I approach it

I have extensive experience with HoLEP. In my practice, I look at the size of the prostate, your medications and what you want to preserve before recommending surgery. I compare HoLEP with the other options and explain what may change in urination and sexual life.

When to see a urologist

If you have an enlarged prostate and medications do not bring enough relief
If you have had urinary retention
If you want to compare HoLEP with other techniques
After surgery, if you have fever, difficulty urinating or blood with clots

Frequently asked questions

What is HoLEP?

It is surgery done through the urethra, with no cuts in the skin. The holmium laser separates the tissue that blocks the flow of urine from the capsule.¹

Is HoLEP suitable for large prostates?

Yes. The European guideline recommends it as an alternative to TURP and open surgery, without naming a weight limit. In large prostates, the results were similar to open surgery, with less time with a catheter and in hospital.¹ In practice, this has to be assessed case by case.

Will I leak urine after HoLEP?

It can happen. In a review of 57 studies, leakage was temporary in 7% and permanent in 1.3% of cases.³

Do erections change after HoLEP?

The European guideline describes an effect comparable to other techniques. In one review, erection scores were slightly higher after enucleation than after TURP in the long term.^1,6

Does ejaculation change?

It usually does. Retrograde ejaculation is very common with the conventional techniques, such as TURP, Greenlight and HoLEP, and in my practice HoLEP almost never preserves ejaculation. If this matters to you, we look at Rezum before deciding.^1,6

How long will I stay in hospital?

In my practice, the stay is usually under 24 hours, and the catheter comes out before discharge.

Can people on blood thinners have HoLEP?

Yes, it is possible. The European guideline describes laser enucleation done safely in men taking these medications.¹

How long do the results last?

In a review with an average follow-up of 7.3 years, a second operation was needed in 4.1% of cases, on average. In a series of 949 men, the improvement in symptoms held at ten years.^4,5

References

EAU Guidelines on the Management of Non-neurogenic Male LUTS. European Association of Urology; 2026. Disease management chapter. EAU
Li S, Zeng XT, Ruan XL, et al. Holmium laser enucleation versus transurethral resection in patients with benign prostate hyperplasia: an updated systematic review with meta-analysis and trial sequential analysis. PLoS One. 2014;9(7):e101615. PubMed
Porreca A, Colicchia M, Tafuri A, et al. Perioperative Outcomes of Holmium Laser Enucleation of the Prostate: A Systematic Review. Urol Int. 2022;106(10):979-991. PubMed
Yim A, Alberto M, Yan X, et al. Comparing GreenLight PVP and HoLEP beyond 5 years: A systematic review of long-term functional outcomes and reoperation rates. BJUI Compass. 2025;6(2):e483. PubMed
Elmansy HM, Kotb A, Elhilali MM, et al. Holmium laser enucleation of the prostate: long-term durability of clinical outcomes and complication rates during 10 years of followup. J Urol. 2011;186(5):1972-6. PubMed
Liu Y, Cheng Y, Zhuo L, et al. Impact on Sexual Function of Endoscopic Enucleation vs Transurethral Resection of the Prostate for Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: A Systematic Review and Meta-Analysis. J Endourol. 2020;34(10):1064-1074. PubMed
Destefanis P, Sibona M, Oderda M, et al. Ejaculation-sparing GreenLight anatomical PVP versus REZŪM for benign prostatic obstruction surgery with an ejaculation-sparing purpose: what are the early differences? Minim Invasive Ther Allied Technol. 2026;35(5):383-391. PubMed
Long Depaquit T, Berchiche W, Uleri A, et al. Two-Year Outcomes of Rezūm Therapy in Real-Life BPH Patients. Prostate. 2026;86(3):314-319. PubMed
McVary KT, El-Arabi A, Roehrborn C. Preservation of Sexual Function 5 Years After Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia. Sex Med. 2021;9(6):100454. PubMed

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