HoLEP (Holmium Laser Enucleation of the Prostate)

What is HoLEP?

HoLEP stands for holmium laser enucleation of the prostate. Working entirely through the urethra, the surgeon uses a laser to separate the obstructing inner portion of the prostate from its outer shell, much like removing the inside of an orange from its peel. The tissue is then removed and sent to pathology. Because the whole obstructing portion is removed rather than partially vaporized or trimmed, HoLEP works for prostates of any size and is considered a size-independent treatment.

Who may benefit from HoLEP?

• Men with a weak stream, straining, frequent urination, or incomplete emptying.
• Men whose symptoms are not controlled by medication, or who prefer to stop medication.
• Men in urinary retention or dependent on a catheter.
• Men with very large prostates who would otherwise be offered open or robotic surgery.
• Men with bladder stones, recurrent infections, or bleeding related to the prostate.

How is the procedure performed?

HoLEP is performed under general or spinal anesthesia. A small scope is passed through the urethra, the laser enucleates the obstructing tissue into the bladder, and a small instrument called a morcellator removes it. Most procedures take one to three hours depending on prostate size. Most patients stay overnight or go home the same day.

What are the benefits?

• Strong, durable improvement in urinary flow and emptying.
• One of the lowest retreatment rates of any BPH procedure.
• Effective for prostates of any size, including very large glands.
• Tissue is sent to pathology, so unsuspected prostate cancer can be identified.
• Can usually be performed safely for men on blood thinners.

What are the alternatives?

Balanced counseling matters more than promoting one operation. Reasonable alternatives include watchful waiting, medication such as alpha blockers or 5-alpha reductase inhibitors, minimally invasive options such as UroLift, Rezum, or iTind, GreenLight photovaporization, TURP, and robotic simple prostatectomy. The right choice depends on prostate size, symptoms, anatomy, sexual function priorities, and your own preferences.

What are the risks?

• Temporary burning with urination and urinary urgency for several weeks.
• Temporary leakage while the bladder and sphincter adjust; long-term leakage is uncommon.
• Blood in the urine that can come and go for several weeks.
• Retrograde ejaculation in most men, meaning semen passes into the bladder.
• Urinary tract infection, urethral stricture, or bladder neck contracture in a small number of patients.

What should I expect before surgery?

• A pre-operative visit to review your history, medications, and goals.
• Instructions on blood thinners, supplements, and diabetes medications.
• A urine culture so any infection is treated before the procedure.
• Nothing to eat or drink after midnight unless told otherwise.
• A responsible adult to drive you home on the day of surgery.

What happens on the day of surgery?

You arrive a couple of hours before your scheduled time, meet the anesthesia team, and confirm the plan. After the procedure you wake up with a catheter that is flushing the bladder with sterile fluid to keep the urine clear. Most patients are up and walking the same day.

Will I have a catheter?

Yes. Nearly all patients wake up with a catheter. It is typically removed the next morning or, less often, within a few days if the urine has not cleared. Most men leave with no catheter at all.

What should I expect during recovery?

• Urgency, frequency, and burning are normal for two to six weeks and then improve steadily.
• Some leakage is common at first and typically resolves with time and pelvic floor exercises.
• Drink plenty of water and avoid straining or heavy lifting for two to four weeks.
• Blood in the urine may reappear around the second or third week as scabs separate.

When can I return to work and exercise?

Desk work is often possible within a week. Heavy lifting, cycling, and strenuous exercise generally wait two to four weeks. Your surgeon will personalize this to your job and your recovery.

What changes can occur with ejaculation?

Most men experience retrograde ejaculation after HoLEP, meaning little or no semen is released during orgasm because it flows backward into the bladder. This is not harmful and does not usually change the sensation of orgasm, but it does affect fertility. Erections are not expected to change.

When should I call the office?

• Fever above 101.5°F or shaking chills.
• Inability to urinate, or a catheter that stops draining.
• Heavy bleeding, or clots that do not clear with increased fluids.
• Pain that is not controlled by your prescribed medication.
• Redness, swelling, or drainage at an incision site.