What is the Holmium Laser Enucleation of the Prostate (HoLEP) procedure?

From the Guidelines

HoLEP is the recommended procedure for the treatment of benign prostatic hyperplasia (BPH) due to its effectiveness in relieving obstruction, low risk of complications, and minimal impact on quality of life. The 2023 European Association of Urology guidelines on the management of non-neurogenic male lower urinary tract symptoms support the use of HoLEP as an alternative to transurethral resection of the prostate (TURP) or open prostatectomy for men with moderate-to-severe LUTS 1.

Key Benefits of HoLEP

• Less bleeding and shorter hospital stays compared to traditional prostate surgeries
• Faster recovery and lower risk of needing repeat surgery
• Effective in relieving obstruction and improving urinary symptoms
• Preserves tissue for pathological examination
• Can be safely performed in patients taking anticoagulant and/or antiplatelet medications, although robust evidence is lacking 1

Comparison to Other Procedures

• HoLEP has similar mid- to long-term efficacy to TURP and open prostatectomy for larger prostates (>80 ml) 1
• HoLEP has a better perioperative safety profile than TURP, with reduced blood loss and fewer blood transfusions 1
• Thulium laser enucleation of the prostate (ThuLEP) and diode laser enucleation of the prostate (DiLEP) are alternative procedures, but the evidence for their use is limited compared to HoLEP 1

Patient Selection and Considerations

• HoLEP is suitable for men with prostate volume >80 ml who require surgical treatment
• Patients should be informed about the potential risks and benefits of the procedure, including the risk of bleeding and the lack of long-term follow-up data
• HoLEP can be offered to patients receiving anticoagulant or antiplatelet therapy, but the evidence for this is weak 1

From the Research

Overview of HoLEP Procedure

• The HoLEP (Holmium Laser Enucleation of the Prostate) procedure is a surgical management option for the treatment of symptomatic benign prostatic hyperplasia (BPH) 2, 3, 4.
• It has become a size-independent gold standard for surgical BPH treatment, with durable long-term subjective and objective outcomes demonstrated in previous studies 2, 4.

Advantages of HoLEP Procedure

• HoLEP has many advantages over traditional gold standards such as open prostatectomy (OP) and transurethral resection of the prostate (TURP), including improved patient outcomes and reduced complications 3, 5.
• It is an efficient and durable procedure, although it is very equipment sensitive and has a relatively long learning curve 3.
• HoLEP can be performed on patients with high risk for postoperative bleeding, or after previous prostate reducing procedures 4.

Efficacy of HoLEP Procedure

• Studies have shown that HoLEP is a safe and effective minimally invasive treatment for BPH, with improved patient prostate specific antigen, American Urological Association symptom score, and maximum urinary flow rate independent of prostate size 6, 5.
• Long-term studies have proven the durability of HoLEP as a first-line surgical therapy for BPH, with favorable and equivalent outcomes regardless of prostate size 2, 4.

Comparison with Other Surgical Therapies

• HoLEP has been compared to traditional therapies for BPH, including TURP, OP, and alternative laser therapies, and has been shown to have greater improvements in post-operative outcomes and lower rates of repeat endoscopic procedures 5.
• Randomized controlled trials have demonstrated that HoLEP can be used to resect adenomas greater than 100 grams with equivalent efficacy to open prostatectomy, but with radically decreased morbidity 5.