If your prostate has grown and you find it hard to pass urine, HoLEP is one of the possible operations. Here I explain what it involves, who it is for, what recovery is like and what side effects it can have, so that you come to your appointment with a clear picture.
Reviewed by Dr. Mario Domínguez Esteban, urologist (medical licence no. 392860199). Head of the Uro-Oncology Section, Marqués de Valdecilla University Hospital.Last reviewed: · Next review: Oct 2027
What it is
HoLEP (holmium laser enucleation of the prostate) is an operation for benign prostatic enlargement, also called benign prostatic hyperplasia (BPH). It is done from inside the urethra, with no cuts in the skin.
With age, the prostate grows. This growth is benign, but it can squeeze the urethra, the tube urine passes through. Then the stream is weak, it is hard to start passing urine, you feel you have not emptied your bladder or you get up several times at night.
To understand the technique, think of a mandarin: HoLEP empties out the segments and leaves the peel. The segments are the tissue causing the blockage (the adenoma), and the peel is the outer part of the prostate. The laser detaches the adenoma, which is pushed into the bladder, where it is broken up and suctioned out with an instrument called a morcellator. The tissue removed is examined in the laboratory.
Who is it for?
First, lifestyle changes and medication are tried. If they are not enough, surgery is considered. Surgery is an option when the symptoms affect your life despite treatment, or when the blockage causes problems such as being unable to pass urine (retention), repeated urine infections, bleeding or bladder stones.
It is a versatile technique: it works for prostates of almost any size, including very large ones, for which open surgery used to be done.
Your case decides. It depends on your prostate, your health and what you expect. Before your appointment, you can measure your symptoms with the IPSS test. If you also have your PSA monitored, see the guide High PSA: what it means and what to do.
What the operation involves
Anaesthesia. It can be general (you are asleep during the operation) or spinal (the lower half of your body is numbed; you are awake but feel no pain). It is decided with you before the operation.
The technique. A thin instrument with a camera (a resectoscope) is passed through the urethra, and the laser fibre goes through it. There are no cuts or stitches in the skin.
Duration. It depends mainly on the size of the prostate. It usually takes a little longer than transurethral resection (TURP).
Catheter. At the end, a catheter is left in the bladder. It drains urine and allows the bladder to be flushed so that clots do not form. According to the EAU patient information, it is usually removed after 1-2 days.
Hospital stay. It is usually short, often 1-2 days.
I will explain at your appointment how long the catheter and hospital stay are expected to be in your case.
Recovery week by week
The first few days. While you have the catheter, your urine may look pink. Once it is removed, it is common to notice burning, urgency or some leakage. This is part of recovery.
The first few weeks. This discomfort usually eases. Some blood may appear in the urine from time to time. Drink water spread throughout the day and avoid heavy exertion and constipation. If you have leakage, pelvic floor exercises help.
From 2-3 weeks. You can resume sexual activity.
The following months. The stream and symptoms keep improving, and the improvement lasts for years. Your urologist will tell you when your check-up is.
Side effects and risks
Retrograde ejaculation. As with TURP, it is common for semen not to come out and to go into the bladder instead; it then leaves the body with urine. It is not harmful, but it affects fertility: if you want to have children, mention it before your operation.
Erections. They do not usually change.
Burning, urgency or leakage. These are common in the first few weeks and usually improve on their own or with pelvic floor exercises. Leakage that persists over time is uncommon, and in studies it occurs at a rate similar to that after TURP.
Bleeding. There is less bleeding than with TURP or open surgery.
Narrowing of the urethra or bladder neck. This is uncommon. If it occurs, the stream becomes weak again and another procedure may be needed.
Urine infection. It can occur, as with any operation through the urethra.
HoLEP compared with TURP, green laser and REZUM
There are several techniques for an enlarged prostate. None is right for everyone:
TURP
Transurethral resection removes the tissue in small fragments. With HoLEP, the strength of the stream improves at least as much (in some studies, a little more in the first year) and the improvement lasts for years. With HoLEP there is less bleeding and the catheter and hospital stay are usually shorter, although the operation takes a little longer. Retrograde ejaculation is common with both.
Open surgery
Open prostatectomy (adenomectomy) is reserved for very large prostates. Compared with it, HoLEP gives a similar result for passing urine, but with less bleeding, a shorter catheter time and hospital stay, and no wound that could become infected.
Green laser
Photovaporisation vaporises the tissue causing the blockage instead of removing it.
REZUM
It applies water vapour to the prostate and is done as an outpatient procedure.
The choice depends on the size and shape of your prostate, your health, the medication you take and whether preserving ejaculation matters to you. We discuss it at your appointment. Dr. Domínguez Esteban is a proctor for Boston Scientific for HoLEP, green laser and REZUM: the declaration of interests at the end of this page gives the details.
Who performs it
Dr. Mario Domínguez Esteban is a urologist and Head of the Uro-Oncology Section at Marqués de Valdecilla University Hospital. He has performed HoLEP since 2018 and has performed more than 500 HoLEP procedures. In the public sector he operates at Marqués de Valdecilla University Hospital and, in the private sector, mainly at Hospital Mompía.
It is a technique that requires experience and specific equipment. That is why it is not available in every centre.
On video
Video in Spanish · 1 min 51 s · Spanish subtitles
Enlarged prostate: what HoLEP is
Why the prostate grows, when surgery is considered and how HoLEP compares with TURP and open surgery.
AI-generated avatar video; script reviewed by Dr. Domínguez Esteban.
Transparency: Dr. Domínguez Esteban acts as a proctor (surgeon trainer) for Boston Scientific (HoLEP or holmium laser enucleation of the prostate, green laser photovaporisation and REZUM) and has declared receiving fees from this company. This video is not sponsored. See all declarations.
Show transcript (English translation)
Do you get up several times at night to urinate? It may be your prostate. And there is treatment.
With age, the prostate grows. It is a benign growth, but it can squeeze the urethra. Then the stream is weak and you go to the toilet more often.
First, lifestyle changes and medication are tried. If that is not enough, surgery is considered.
One option is HoLEP: holmium laser enucleation of the prostate. It is done from inside the urethra, without cuts. The laser separates the tissue that is causing the blockage. It is like scooping the segments out of a mandarin and leaving the peel.
It is a versatile technique: it works for prostates of almost any size.
And compared with transurethral resection of the prostate, or TURP? The strength of the stream improves at least as much. In some studies, slightly more in the first year. And the improvement lasts over the years. There is also less bleeding. And the catheter time and hospital stay are usually shorter.
Compared with open surgery, or simple prostatectomy, the urinary result is similar. But there is less bleeding, and the catheter time and hospital stay are shorter. And, with no cuts, there is no wound that can become infected.
It is a technique that requires experience and specific equipment. That is why it is not available in every centre.
As with TURP, it is common for semen not to come out. This is retrograde ejaculation. Erections do not usually change. In the first few weeks there may be stinging, urgency or some leakage. This usually improves.
Your case decides. It depends on your prostate, your health and what you expect.
Before your appointment, measure your symptoms with the IPSS test at drdominguezesteban.com.
When to seek help
Seek urgent medical attention if you cannot pass urine, if you have a fever or if you pass clots in your urine.
Book a priority appointment with your doctor if, after a few weeks, the leakage or burning does not improve, or if the stream becomes weak again.
TURP removes the tissue in small fragments; HoLEP detaches it whole with the laser, like emptying the segments of a mandarin. With HoLEP the improvement in passing urine is at least as good, there is less bleeding and the catheter and hospital stay are usually shorter. Retrograde ejaculation is common with both.
How long is recovery after HoLEP?
Discomfort when passing urine (burning, urgency or some leakage) is common in the first few weeks and usually eases. Sexual activity can be resumed from 2-3 weeks. Symptoms keep improving over the following months.
How many days will I have a catheter and stay in hospital?
According to the EAU patient information, the catheter is usually removed after 1-2 days and the hospital stay is usually 1-2 days. I will explain what to expect in your case.
Does it cause incontinence?
Some leakage is common in the first few weeks, and it usually improves on its own or with pelvic floor exercises. Leakage that persists over time is uncommon.
Does it affect sex life: erections and ejaculation?
Erections do not usually change. Retrograde ejaculation is common: semen goes into the bladder instead of coming out. It is not harmful, but it affects fertility.
What anaesthesia is used?
General or spinal. It is decided with you before the operation.
Does it work if the prostate is very large?
Yes. It works for prostates of almost any size, including very large ones, for which open surgery used to be done.
HoLEP, TURP, REZUM or green laser: which suits my case?
It depends on the size and shape of your prostate, your health, the medication you take and what you expect, for example whether preserving ejaculation matters to you. We discuss it at your appointment.
How long does the operation take?
It depends mainly on the size of the prostate. It usually takes a little longer than a TURP. I will give you an estimate for your case at your appointment.
How long can there be blood in the urine?
While you have the catheter, urine may look pink. In the following weeks there may be some blood now and then, especially after exertion. Drink water spread through the day and avoid constipation. Seek urgent medical attention if you pass clots or cannot pass urine.
When can I go back to work, drive or exercise?
It depends on your job and how you recover. Light activity can be resumed soon; heavy exertion, lifting and cycling are best avoided for the first few weeks. I will give you specific timings when you are discharged.
What happens to PSA after HoLEP?
Because the obstructing tissue is removed, PSA usually falls after the operation. It is useful to know your new baseline value for future follow-up. More information in High PSA.
Do I need to stop blood thinners?
Tell us if you take anticoagulants or antiplatelet drugs. We will tell you whether and when to stop or adjust them. Do not stop them on your own.
Can the prostate grow back?
HoLEP removes the obstructing tissue and the improvement lasts for years. Needing another operation for the same reason is uncommon.
Is it covered by my insurance or the public health system?
Coverage depends on each policy; Urología Mínimamente Invasiva (UMI) can tell you. In the public health system in Cantabria, HoLEP is performed at Marqués de Valdecilla University Hospital: your GP refers you to the Urology department.
If you would like me to assess your case, Where I see patients explains how to book an appointment, both in the public and in the private sector.
Dr. Domínguez Esteban acts as a proctor (surgical trainer) for Boston Scientific (HoLEP or holmium laser enucleation of the prostate, green laser photovaporisation and REZUM) and has declared receiving fees from this company. This page is not sponsored. Full declaration of interests: Transparency.