What is holmium laser enucleation of the prostate (HoLEP)?

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What is HoLEP?

HoLEP (Holmium Laser Enucleation of the Prostate) is a size-independent endoscopic surgical procedure that uses a holmium laser (wavelength 2,140 nm) to dissect and remove entire prostatic lobes from the surgical capsule, followed by transurethral morcellation of the tissue—it is now recognized as the modern gold standard for surgical treatment of benign prostatic hyperplasia (BPH) regardless of prostate size. 1, 2

Surgical Technique

HoLEP involves three key steps:

  • The holmium laser fiber dissects whole prostatic lobes off the surgical capsule in retrograde fashion while maintaining excellent hemostasis 3
  • The enucleated lobes are pushed into the bladder 3
  • A purpose-built transurethral morcellator removes the tissue from the bladder, enabling endoscopic treatment of even very large prostates 3

Clinical Indications and Advantages

HoLEP is indicated for lower urinary tract symptoms (LUTS) secondary to BPH and offers several advantages over traditional transurethral resection of the prostate (TURP):

  • Size-independent application: Can effectively treat prostates of any size, from 20 cm³ to over 350 cm³, making it suitable as an alternative to both TURP and open prostatectomy 4, 5
  • Superior tissue removal: Removes significantly more prostatic tissue than TURP (mean 40.4 g vs 24.7 g), resulting in more complete enucleation 3
  • Better urodynamic outcomes: Achieves superior relief of bladder outlet obstruction compared to TURP, with lower postoperative detrusor pressure at maximum flow (20.8 vs 40.7 cm H₂O at 6 months) 3
  • Faster recovery: Shorter catheterization time (17.7 vs 44.9 hours) and hospital stay (27.6 vs 49.9 hours) compared to TURP 3

Guideline Recommendations

Both major urological societies endorse HoLEP as a primary surgical option:

  • The American Urological Association (AUA) recommends HoLEP as a size-independent endoscopic treatment option for LUTS/BPH (Moderate Recommendation; Evidence Level: Grade B) 1, 6
  • The European Association of Urology (EAU) similarly recommends HoLEP as a size-independent alternative to TURP or open prostatectomy 1, 6

Long-Term Efficacy and Durability

HoLEP demonstrates excellent long-term functional outcomes:

  • Durable symptom improvement extending beyond 10 years of follow-up 2
  • 200% increase in maximum urinary flow rate (Qmax) and 75% improvement in International Prostate Symptom Score (IPSS) at 1 year, with continued improvement during subsequent follow-up 4
  • Very low rates of reintervention, confirming durability of results 7
  • Postoperative PSA decreases by an average of 91.7% and prostate volume decreases by 85.9% on transrectal ultrasound, supporting completeness of enucleation 5

Safety Profile and Complications

HoLEP has a favorable safety profile with low complication rates:

  • No deaths or transurethral resection (TUR) syndrome reported in large series 5
  • Low transfusion rate (approximately 2% overall; 11 of 552 patients in one series, with 8 of those on anticoagulation) 4
  • Safe for high-risk patients: Can be performed safely in patients requiring anticoagulation or dual antiplatelet therapy 1, 6
  • Common minor complications include transient irritative symptoms (9.4%), transient stress incontinence (4.2%), bladder neck contracture (1.3%), and urethral stricture (1.3%) 4

Special Considerations

Ejaculation preservation:

  • Standard HoLEP typically results in retrograde ejaculation, similar to TURP 1
  • Ejaculatory hood-sparing techniques have been studied for ejaculation preservation, though this remains investigational 1

Operative time:

  • HoLEP requires longer operative time than TURP (mean 62.1 vs 33.1 minutes for standard cases; up to 166.8 minutes for very large prostates >75 g) 3, 5
  • However, the efficiency of tissue retrieval is similar when accounting for the greater volume of tissue removed 3

Clinical Decision-Making

HoLEP should be considered for:

  • Patients with large prostates (>80 g) requiring maximal tissue removal 6
  • Patients on anticoagulation or with high bleeding risk 1, 6
  • Patients prioritizing long-term functional outcomes and low reoperation rates 6, 2
  • Any patient with symptomatic BPH regardless of prostate size who desires definitive surgical treatment 1, 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

6
Guideline

HoLEP and Rezum for BPH Treatment

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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