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HoLEP Procedure Pros & Cons

Author Quynh-Chi Dang covers HoLEP Procedure Pros & Cons on BackTable Urology

Quynh-Chi Dang • Jun 5, 2021 • 8.7k hits

A HoLEP procedure, or holmium laser enucleation of the prostate, is a new BPH treatment that is widely used because of its minimal invasiveness and quicker recovery times compared to traditional prostatectomies. However, urologists should evaluate the HoLEP procedure pros and cons before deciding to perform the HoLEP prostate surgery. Two limitations of the HoLEP procedure are the patient’s prostate anatomy and the risk of anejaculation. Dr. Roerhborn explains the HoLEP procedure steps in the context of other BPH treatments, including KTP laser, Aquablation, TURP, Urolift, and Rezum.

We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable Urology Brief

• Different BPH surgical options can be categorized based on invasiveness, use of ablation, implantation, energy source, and anatomical approaches.

• A HoLEP procedure is an enucleation technique that involves the use of a holmium laser to resect large portions of the prostate. It is sometimes preferred because of its minimal bleeding risk and endoscopic approach.

• HoLEP prostate surgery is not an ideal surgical treatment for prostates greater than 80 g, as it requires great surgical skill and precision as well as an extended operating time.

• Because the HoLEP procedure steps involve making incisions at the bladder neck, the risk of anejaculation after surgery is higher when compared to other BPH surgical treatments, such as Urolift, Rezum, and Aquablation.

• The HoLEP procedure can be used to resect medium-sized prostates (30-80 g) and those with substantial median lobes.

HoLEP procedure surgery

Table of Contents

(1) HoLEP Procedure Overview

(2) HoLEP Procedure Limitations for Large Prostates (>80 g)

(3) HoLEP Procedure Limitations for Antegrade Ejaculation Preservation

(4) HoLEP Surgery Advantages for Medium-Sized Prostates (30-80 g) & Substantial Median Lobes

HoLEP Procedure Overview

The HoLEP procedure (holmium laser enucleation of the prostate) is a popular technique among the minimally invasive options for BPH. There are a variety of new BPH treatments that can be categorized in a multitude of ways: minimally invasive vs. full anesthesia, ablative vs. non-ablative, permanent vs. temporary device implantation, and laser vs. other energy sources. HoLEP procedure steps involve accessing the urethra endoscopically and using a holmium laser to resect large sections of the prostate without substantial bleeding. Then, a morcellator digests the excised prostate pieces into smaller pieces in the bladder, allowing them to be removed.

[Dr. Aditya Bagrodia]
...As we start talking about the relevant patient characteristics, symptom characteristics, and anatomical considerations, perhaps it would be useful, Claus, if you could give a comprehensive list of options that are available, as you see it.

[Dr. Claus Roehrborn]
...Those treatments nowadays are grouped into minimally invasive (done as an outpatient or an ambulatory surgery center) versus the surgeries that require full anesthesia (done in a hospital setting usually and require more or less an overnight stay).

...You can also group these treatments by if they remove tissue or if they do not remove tissue. I'll give you an example. A TURP classically removes tissue. It's an ablative procedure and it's invasive and it requires hospitalization at least for a day. Non-ablative would be a UroLift. You place the UroLift devices and you push the tissue to the side but no tissue is ultimately removed. So ablative versus non-ablative is another way of differentiating it.

There would be a differentiating between treatments that consist of permanent placement of items, such as a UroLift, and there's a whole slew coming down the pipe, the Zenflow device, the Butterfly device, the Medeon device, all of which are experiencing trials in the United States right now and may or may not be approved by the FDA. Versus treatments that don't use devices that are implanted permanently.

And then there's the categorization by devices that work by laser energy versus electrocautery energy versus other energies. For example the Rezum procedure uses steam, just hot water heated by radio frequency energy, and then is injected and as the steam gives off the energy it destroys the tissue. So the energy source is another question. And to add to that, there is the Aquablation treatment that doesn't use any heat per se--neither electrical generated heat nor laser generated heat nor steam--but it uses basically saline at room temperature with a very intense water pick system to destroy prostate tissue.

You can already see how complex it is, how you can group these treatments by energy source, by ablative or non-ablative, by implant versus non-implant. Then comes the question: are these treatments all suitable for all sizes and shapes? But if you look through the list, minimally invasive devices currently approved and recommended in the United States would be the UroLift device, which is an implant, and the Rezum treatment, which is a steam-based heat treatment that partially ablates tissue. Then amongst the surgical treatments there would be monopolar/bipolar TURP, the PVP, the GreenLight or KTP or 532nm laser ablation of the prostate. Then there would be a host of enucleation techniques and, as you know, enucleation now can be done with the traditional way, the holmium laser enucleation which is called HoLEP, the thulium laser which is called ThuLEP, but people do it with the green-light laser as well and it's called KTP laser enucleation, or even do it with a bipolar resectoscope device and just get into the enucleation plane.

Then we have the treatments for the very large prostates that go beyond the HoLEP or ThuLEP, the robotic or open or robotic-assisted laparoscopic enucleation of the prostate as alternatives for the very large prostates.

Listen to the Full Podcast

Contemporary Surgical Management of BPH with Dr. Claus Roehrborn and Dr. Aditya Bagrodia on the BackTable Urology Podcast)
Ep 6 Contemporary Surgical Management of BPH with Dr. Claus Roehrborn and Dr. Aditya Bagrodia
00:00 / 01:04

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HoLEP Procedure Limitations for Large Prostates (>80 g)

Classifying prostates by size is subjective because of varying surgical skill levels. However, Dr. Roehrborn personally defines large prostates as those greater than 80 g. One HoLEP procedure con, or limitation, is that it requires a very skilled surgeon, and its morcellation step would significantly extend the procedure and anesthesia time. Due to this, Dr. Roehrborn prefers to perform transvesical robotic assisted laparoscopic enucleation on large prostates. However, if he is not able to gain transvesical access, he would perform the HoLEP procedure, as it requires a transurethral approach.

[Dr. Aditya Bagrodia]
...So let's start out with large prostates. A, how do you define that?

[Dr. Claus Roehrborn]
That was a heavy debate amongst the BPH guideline committee members: what is large? And some people, even the peer reviewers of the guidelines said, "Give us guidance. Give us numbers." And we refuse. Because some people can resect a 60 g prostate, some can resect an 80 g prostate, some can resect 100g prostate and we don't restrict that. So what is large is a little bit in the eye of the beholder. We suggest that large for most doctors starts at 80g. Because I really doubt that many of our current trainees can resect 40 or 50 g of tissue safely. Why would I say 40, 50? Because that's the transition zone tissue you want to resect if you're faced with an 80 or 90 g prostate. That's how much you want to resect. And most of them can't. So to me, large starts at 80. Anything above 80, either I want to sit there for 4 hours and do a KTP laser, which is still incomplete, or I do a bipolar TURP and I'll do it all myself with no trainee involved to do it quickly, or I just go to the category large prostates, which starts at 80 and goes to the 100 g or 200 g and 300 g.

And in that category, the best choices right now are no longer the open prostatectomy either retropubic, the old Millin approach, or suprapubic, but the best choices are either a robotic assisted laparoscopic enucleation, which 90% is done transvesical. Only 10% is done retropubically, opening the capsule. It's just the robot is not really well suited to do it, and you'd have to release the bladder, like for a radical prostatectomy, so there's a lot of reasons not to do it. It's a transvesical robotic assisted laparoscopic, which works extremely well. Sizes 80 to infinity. Now, there are 20, 30, 40, 50 places in the United States where there are real experts who can do holmium enucleation or a thulium enucleation, and this is the same thing. The sky is the limit. They enucleate prostates from 80 to 150, 200, 300 g.

What happens, though, is after a robotic enucleation, you put the prostate in the bag and you take the bag out and if the prostate is 100 g or 200 g takes the same time. The morcellation, as you know, takes longer. So you enucleate transurethrally 250 g or so, the morcellation time takes longer. So maybe this is a detriment for HoLEP in 200 g, 300 g and the benefit of the robotic assisted enucleation. But then again, there are patients who had prior surgery or have reasons not to do a laparoscopic surgery for whom only the transurethral approach is applicable.

[Dr. Aditya Bagrodia]
Okay, fantastic. I'll just try to briefly summarize. Large prostates, we're looking at bipolar TURP, can be technically challenging, comes with fluid and temperature changes, potential bleeding risks that are considerations. KTP prostatectomy, I think you need to be committed for the long haul to really get a good job and serve the patient well. Then you've got the simple prostatectomy, probably most frequently done via a minimally invasive approach with the benefit of avoiding an enucleation step, and of course conversely it is a transabdominal surgery. And then lastly the HoLEP procedure, a minimally invasive option, technically challenging, limited to certain areas of expertise, and then the morcellation step.

HoLEP Procedure Limitations for Antegrade Ejaculation Preservation

A common concern that BPH patients have before HoLEP prostate surgery is the risk of anejaculation, which is the loss of the ability to ejaculate during sexual climax. Anejaculation can be attributed to interference with the apical tissue in front of the verumontanum and making incisions in the bladder neck. Dr. Roehrborn explains that a HoLEP procedure may not be the optimal surgical option if the patient prioritizes ejaculation preservation, since HoLEP procedure steps involve making bladder neck incisions before enucleation.

[Dr. Aditya Bagrodia]
Okay, fantastic. If I may, for smaller glands of course there's going to be some considerations and perhaps I would ask for you to speak a little bit about transurethral incision of the prostate and even a little bit more broadly on options that are going to be prioritized when preservation of antegrade ejaculation is a priority.

[Dr. Claus Roehrborn]
It used to be said that ejaculation has to do a lot with the bladder neck and every time you mess with the bladder neck you get anejaculation or retrograde ejaculation. And then there is a school of thought that says the antegrade ejaculation hinges on the apical tissue that is right in front of the verumontanum. Currently, most people think that it's just the apical tissue that preserves the ejaculation. Now, just in our meeting this morning I raised this question because it is known that the incision of the bladder neck actually causes 30 to 50% retrograde ejaculation even if you don't come close to the verumontanum. So I'm old school there. I think the bladder neck must play a role in it, perhaps not the only role….

If a man comes in and says ejaculation trumps, then I'll look at him and say, "Okay, let me check your prostate size." If the prostate size is 30, 40, 50 g I say, "Let's try a UroLift." If it's a really small prostate I say, "You can try a UroLift. We can also try an incision and I'm not carrying it all the way to the veru. We can see how that works." If it's a larger prostate I say, "Well, let's do the Aquablation treatment because that will give you the best chances of preserving antegrade ejaculation."

Now, full stop. There's a lot of surgeons who claim they can preserve ejaculation to 70, 80, 90% even doing a TURP, doing a GreenLight laser, doing a HoLEP, as long as they preserve this hood of tissue in front of the verumontanum. Well, the problem is that that doesn't seem to be easy to duplicate by others, A. B, the very principle of the HoLEP surgery is to make an incision in the mucosa at the apical tissue, so that tissue by definition has to go as part of the package. So I'm really unclear on that. And most of these studies are single center, single investigator. So I'm less enthusiastic about this idea of leaving a little tissue behind close to the verumontanum and I secondarily don't believe you achieve the same efficacy necessarily. So, ejaculation preservation. UroLift tops. Rezum second for the smaller glands. Aquablation for the larger glands. And then comes all this artistry and the individual people who can do it, presumably, with good success, even when they do a standard TURP.

HoLEP Surgery Advantages for Medium-Sized Prostates (30-80 g) & Substantial Median Lobes

All BPH treatment options, including HoLEP surgery, are available for medium-sized prostates. Bipolar TURP, Greenlight (KTP) laser, HoLEP, Aquablation, and Rezum are appropriate for prostates with substantial median lobes.

[Dr. Aditya Bagrodia]
Okay, fantastic. Now we're moving away from the large prostates--the Texas-size prostates--more to average and smaller prostates and perhaps just to give the next layer of options some categorization and phylogeny.

[Dr. Claus Roehrborn]
Clearly for the average size prostate there are a plethora of things that can be done. Both the Rezum and the UroLift are recommended by the AUA guidelines between 30 and 80 g. This was done during the studies. This was the size range that was tested. The Teleflex or NeoTract company has also done a study in patients up to 100 g and the FDA approved UroLift but I personally don't like to use it above 80g. I think I stick with 30 to 80 g. In that same category is also HoLEP and ThuLEP. In the same category is the KTP laser. In the same category is the transurethral resection or even transurethral vaporization with electrocautery.

[Dr. Aditya Bagrodia]
Maybe I'll interrupt you for just a moment, Claus, and ask you, among all of these options, of which pretty much everything is available, how does the median lobe presence or absence affect your decision?

[Dr. Claus Roehrborn]
So big decision point, the intravesical lobe. No medical therapy. Please don't give medical therapy for substantial intravesical lobe ever. Doesn't work and it's just a waste of time and money. Choose your weapon carefully. If you have access to not much then use your TURP loop. It's the best tool yet. If you have it and you're really good at it you can use the GreenLight laser. You certainly can use the HoLEP. The Aquablation, but caveat, you may have to resect tissue at the end of that Aquablation. And if you have the Rezum you can do it and stick the needle in. And use the UroLift only if you're really, really good at that because it's a technically difficult move to make.

Additional resources:

Podcast Contributors

Dr. Claus Roehrborn discusses Contemporary Surgical Management of BPH on the BackTable 6 Podcast

Dr. Claus Roehrborn

Dr. Claus Roehrborn is a urologist with UT Southwestern in Dallas, Texas.

Dr. Aditya Bagrodia discusses Contemporary Surgical Management of BPH on the BackTable 6 Podcast

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Cite This Podcast

BackTable, LLC (Producer). (2021, April 23). Ep. 6 – Contemporary Surgical Management of BPH [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



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