HoLEP Surgery | Holmium Laser Enucleation of the Prostate

What is HoLEP?

Holmium Laser Enucleation of the Prostate (HoLEP) is a minimally invasive endoscopic operation to treat a symptomatic enlarged prostate gland (benign prostatic hyperplasia, or BPH). A fine telescope is passed through the urethra — no skin incisions are made — and a holmium laser is used to separate the obstructing inner portion of the prostate (the adenoma) cleanly from its outer capsule, in the same anatomical plane that open prostatectomy used historically.

The enucleated tissue is then drawn back into the bladder and a second instrument (a morcellator) reduces it to small pieces that are washed out. Because the tissue is removed intact rather than vaporised, it can be sent to the pathology laboratory for analysis.

Dr Hadjipavlou uses the Boston Scientific / Lumenis 100W Moses laser system — a pulsed-delivery technology that optimises energy transfer to tissue and reduces fluid absorption during the procedure.

The result is a widely patent channel through which urine flows freely — functionally equivalent to open prostatectomy, achieved endoscopically.

Who is HoLEP suitable for?

HoLEP is performed for men with symptomatic BPH who have not responded sufficiently to medication, or who prefer a definitive surgical solution. It is particularly well suited to men with:

Prostate glands of any size, including very large glands (>80 g, >100 g, or larger) where other endoscopic techniques are not straightforward
Retention of urine requiring a long-term catheter
Recurrent urinary tract infections related to incomplete bladder emptying
Bladder stones caused by chronic retention
Renal impairment related to high-pressure obstruction
A preference to avoid long-term medication

Men who wish to preserve ejaculatory function should discuss the high rate of retrograde ejaculation associated with HoLEP (and indeed with all anatomical surgical treatments for BPH) before deciding on treatment. For such men, UroLift® or Rezūm® may be worth considering, depending on prostate characteristics.

What to expect: before, during, and after

Before the procedure

Pre-operative assessment includes a urine flow rate measurement, post-void residual ultrasound, and blood tests. If you take blood-thinning medication, specific guidance will be given about when to pause it. An anaesthetic assessment will be arranged.

During the procedure

HoLEP is performed under general or spinal anaesthesia. The operation typically takes approximately 60 minutes. A urinary catheter is placed at the end of the procedure.

After the procedure

You will wake with a urinary catheter in place. There is commonly some blood in the urine for the first 24–48 hours, which settles. The catheter is typically removed the morning after surgery, after which voiding is confirmed before discharge. Most patients are home within one to two days.

In the weeks following surgery, some urgency and frequency of urination is common as the bladder adjusts to its new outflow. These symptoms generally resolve over 4–8 weeks. Full symptomatic benefit is usually apparent by 6–12 weeks.

Results and recovery

HoLEP produces durable improvement in urinary flow rate and symptom scores. Published series consistently demonstrate low retreatment rates at 5 and 10 years. Because the entire adenoma is removed in the correct anatomical plane — rather than being partially resected or vaporised — regrowth of obstructing tissue is uncommon.

The tissue removed at HoLEP is routinely examined by the pathology laboratory. Incidental prostate cancer is identified in a small proportion of specimens; where detected, this allows timely discussion about further management.

Most men notice a significant improvement in urinary symptoms within a few weeks of surgery. Full recovery and the establishment of good urinary function typically takes 6–12 weeks.

Treatment Comparison for Benign Prostatic Hyperplasia

This table is for general information only. Your surgeon will advise which treatment is most appropriate for your situation.
Feature	HoLEP	TURP
Technique	Laser enucleation — the entire obstructing tissue is separated and removed whole	Electrosurgical resection — tissue is chipped away piece by piece
Prostate size	Any size — EAU Guidelines recommend HoLEP as the preferred option for prostates over 80 g	Usually up to ~80 g
Hospital stay	1–2 nights	2–3 nights
Catheter after procedure	1–2 days	3–5 days
Blood loss	Lower — the laser seals vessels as it works	Higher — greater bleeding risk, especially in larger prostates
Long-term durability	Very low retreatment rate — tissue is fully removed and cannot regrow	Higher retreatment rate over time — residual tissue can regrow
Evidence base	Over 25 years of published outcomes	Established gold standard for decades

Frequently Asked Questions

: The procedure typically takes approximately 60 minutes.
: Most patients are discharged the day after surgery, after the urinary catheter has been removed and voiding confirmed. Some patients with very large prostates may stay a second night.
: Light activity can usually resume within 1–2 weeks. Strenuous exercise and heavy lifting should be avoided for 4–6 weeks. Most men return to desk work within 1–2 weeks.
: Retrograde ejaculation — where semen passes backwards into the bladder during orgasm — is a common outcome of HoLEP, occurring in the majority of men. This does not affect the sensation of orgasm or erectile function. Men who wish to father children should discuss this carefully before proceeding.
: Yes. Unlike some other surgical approaches, HoLEP has no upper prostate size limit. It has been performed on glands exceeding 400 grams. This makes it suitable for men who have been told their prostate is too large for other procedures.
: HoLEP removes the obstructing tissue completely, giving durable long-term results. Re-operation rates at 10 years are very low — significantly lower than after TURP or laser vaporisation in most published series.
: Yes. The enucleated tissue is sent to the pathology laboratory. This means any unexpected areas of prostate cancer within the obstructing tissue are detected, which is not possible with vaporisation techniques.