Does Holmium Laser Enucleation of the Prostate (HoLEP) cause retrograde ejaculation?

Retrograde Ejaculation After Holmium Laser Enucleation of the Prostate (HoLEP)

Yes, HoLEP causes retrograde ejaculation in the majority of patients, with studies showing rates of 53.8-73.1% of patients experiencing complete loss of antegrade ejaculation following the procedure. 1, 2, 3

Incidence and Evidence

• According to the European Association of Urology guidelines, ejaculatory dysfunction is a common side effect of HoLEP, affecting approximately 53.8% of patients 1
• A 2015 study found that 70.3% of patients experienced complete loss of antegrade ejaculation after HoLEP 3
• Even with attempts to preserve ejaculatory function using specialized techniques, retrograde ejaculation remains common:
  • In a study comparing conventional HoLEP with ejaculatory hood sparing technique (EH-HoLEP), semen was completely absent in 53.8% of the EH-HoLEP group and 73.1% of the conventional HoLEP group 2
  • The overall success rate for ejaculation preservation was only 46.2% even with specialized techniques 2

Mechanism and Contributing Factors

The high rate of retrograde ejaculation with HoLEP is primarily due to:

1. Complete removal of apical prostatic tissue during the procedure 2
2. Disruption of the bladder neck mechanism that normally prevents retrograde flow during ejaculation
3. The enucleation technique itself, which is designed to completely remove the adenoma 1

Patient Perception and Bother

Interestingly, despite the high rates of retrograde ejaculation:

• Recent studies show that patients do not find this change particularly bothersome 4
• The 2024 study found no significant decline in the "bother" question scores (2.552 pre-HoLEP vs. 3.119 post-HoLEP, p = 0.526) despite significant declines in ejaculatory ability, strength, and volume 4
• Patient education about this side effect has improved, with implementation of surgeon-patient handouts increasing understanding of retrograde ejaculation (pre-handout: 41/46 vs. post-handout: 50/50, p=0.022) 5

Erectile Function After HoLEP

While retrograde ejaculation is common, erectile function is generally preserved:

• There is no significant decline in erectile function scores after HoLEP (11.51 pre-HoLEP vs. 13.327 post-HoLEP, p = 0.498) 4
• Similar short and mid-term erectile function changes compared to TURP, with better long-term IIEF scores than TURP 1

Alternative Options for Ejaculation Preservation

For patients who prioritize preservation of ejaculatory function:

• Rezum water vapor therapy offers better preservation of ejaculatory function compared to HoLEP 1
• Specialized ejaculatory hood sparing techniques during HoLEP may improve ejaculation preservation rates, though results are still suboptimal (46.2% preservation with specialized technique vs. 26.9% with conventional HoLEP) 2

Clinical Implications

• Proper patient counseling about the high likelihood of retrograde ejaculation is essential before proceeding with HoLEP
• For sexually active men who wish to maintain ejaculatory function, alternative treatments like Rezum may be more appropriate 1
• Patients should understand that while ejaculatory function is likely to be affected, erectile function is generally preserved after HoLEP 4