Holmium Laser Enucleation of the Prostate (HoLEP)
HoLEP is a size-independent surgical treatment for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) that should be considered as a primary surgical option, particularly for patients with large prostates, those on anticoagulation, or those requiring durable long-term outcomes. 1
What HoLEP Is and How It Works
HoLEP uses holmium laser energy to enucleate (completely remove) prostatic adenoma tissue through the urethra, followed by mechanical morcellation to extract the tissue from the bladder 2, 3. The holmium laser has water as its chromophore with minimal tissue depth penetration, achieving rapid vaporization and coagulation without deep tissue penetration, resulting in superior hemostatic properties compared to monopolar or bipolar TURP 1.
Primary Indications for HoLEP
Prostate size-independent treatment: HoLEP can be performed on prostates of any size, from small glands to very large prostates exceeding 80g, making it superior to size-limited procedures like Rezum (limited to <80g) or TUIP (limited to <30g) 1, 4.
High bleeding risk patients: HoLEP should be specifically considered for patients on anticoagulation or antiplatelet therapy 1. The need for blood transfusion is significantly lower with HoLEP compared to TURP (RR: 0.20; CI: 0.08,0.47) 1. Anticoagulation therapy has not been shown to adversely affect HoLEP outcomes, other than slightly increased duration of bladder irrigation and hospital stay 1, 5.
Patients requiring maximal tissue removal: HoLEP removes more prostatic tissue than TURP, with one randomized trial showing 15.7 grams greater tissue removal, resulting in greater PSA reduction and superior long-term outcomes 3.
Expected Outcomes and Durability
Symptom improvement: HoLEP provides significant and sustained improvement in LUTS with durability exceeding 10 years 3. At 7-year follow-up, HoLEP demonstrated superior outcomes compared to TURP including Qmax improvement (4.36 mL/s better), erectile function (2.39 points better on IIEF), and greater tissue removal 3.
Retreatment rates: HoLEP has lower retreatment rates compared to other endoscopic BPH procedures, demonstrating superior long-term durability 5, 3.
Functional outcomes: Approximately 75% of patients experience retrograde ejaculation after HoLEP 5. Incontinence is rare, and immediate complication rates are low 5, 3.
Special Patient Populations
Patients with detrusor underactivity: HoLEP can be carefully applied to patients with detrusor underactivity or acontractility, as most patients with retention and documented detrusor underactivity can still benefit from outlet procedures 5.
Patients with prostate cancer: HoLEP can be considered in patients undergoing active surveillance for low-risk prostate cancer 5, 6. Screening for prostate cancer with PSA and MRI is recommended before HoLEP, as >10% will have incidental cancer detected 6.
Retreatment setting: HoLEP has been successfully used in patients who have had previous prostate operations 5.
Comparison to Alternative Procedures
Versus TURP: HoLEP is superior to TURP with better long-term outcomes, lower retreatment rates, less bleeding risk, and ability to treat larger prostates 1, 3.
Versus Rezum (water vapor therapy): For prostates >80g, HoLEP is the only option between these two 4. For prostates <80g, HoLEP provides superior objective functional outcomes and long-term durability, while Rezum offers better ejaculation preservation 4.
Versus ThuLEP (Thulium laser): Both HoLEP and ThuLEP are considered equivalent size-independent options, with choice depending on surgeon expertise 1.
Technical Considerations and Learning Curve
HoLEP is equipment-sensitive and has a relatively long learning curve 2. The procedure can be performed using several surgical approaches (classic 3-lobe, modified 2-lobe, or en-bloc techniques) adapted to patient-specific anatomy 2. Advances in laser technology and endoscopic morcellation devices have improved efficiency, hemostasis, and safety 2, 3.
Guideline Recommendations
The American Urological Association provides a Moderate Recommendation (Evidence Level: Grade B) that clinicians should consider HoLEP as a prostate size-independent suitable option for treatment of LUTS/BPH 1. The European Association of Urology similarly endorses HoLEP as a size-independent treatment option 1, 4.