HoLEP: The Gold Standard in Minimally Invasive Prostate Surgery — A Comprehensive Guide
Holmium Laser Enucleation of the Prostate (HoLEP) represents the most advanced minimally invasive surgical treatment for benign prostatic hyperplasia (BPH). Dr. Chui Ka Lun, a pioneer who introduced HoLEP to Hong Kong, explains how this technique delivers superior outcomes with faster recovery compared to traditional surgery.
Introduction
Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting men as they age. By the age of 60, approximately 50% of men develop some degree of prostatic enlargement, and by 85, the prevalence rises to nearly 90%. When the enlarged prostate compresses the urethra, it causes bothersome lower urinary tract symptoms (LUTS) including frequent urination, weak stream, incomplete emptying, nocturia, and in severe cases, acute urinary retention.
While medications such as alpha-blockers and 5-alpha reductase inhibitors can provide initial relief, many patients eventually require surgical intervention when medical therapy fails to adequately control their symptoms. For decades, transurethral resection of the prostate (TURP) has been the standard surgical approach. However, the introduction of Holmium Laser Enucleation of the Prostate (HoLEP) has fundamentally transformed the landscape of BPH surgery, offering a technique that is safer, more durable, and applicable to prostates of any size.
What Is HoLEP?
HoLEP stands for Holmium Laser Enucleation of the Prostate. It is a minimally invasive endoscopic procedure that uses a high-powered holmium laser (wavelength 2,140 nm) to precisely enucleate (shell out) the obstructing prostatic adenoma from the surrounding surgical capsule. The enucleated tissue is then pushed into the bladder and removed using a morcellation device.
The holmium laser operates in a pulsed mode with a penetration depth of only 0.4 mm, which allows for extremely precise tissue cutting while simultaneously coagulating blood vessels within a zone of 0.5 to 1.0 mm. This dual capability — cutting and coagulating — is what makes HoLEP uniquely effective compared to other surgical techniques [1].
Unlike TURP, which shaves prostate tissue in small chips from the inside out, HoLEP follows the natural anatomical plane between the adenoma and the surgical capsule, essentially replicating the principle of open prostatectomy but through a minimally invasive endoscopic approach. This anatomical enucleation ensures more complete tissue removal and significantly lower recurrence rates [2].
Why HoLEP Is Considered the Gold Standard
The European Association of Urology (EAU), the American Urological Association (AUA), and the National Institute for Health and Care Excellence (NICE) all recommend HoLEP as a first-line surgical option for BPH, particularly for prostates larger than 80 mL [3] [4]. Several key advantages underpin this recommendation:
Size Independence
Unlike TURP, which becomes increasingly challenging and risky for prostates exceeding 80 grams, HoLEP can be safely and effectively performed on prostates of any size — from 30 mL to over 300 mL. This versatility eliminates the need for open prostatectomy in patients with very large glands [3].
Superior Long-Term Durability
A landmark 7-year randomised controlled trial by Gilling et al. confirmed that HoLEP provides outcomes at least equivalent to TURP, with significantly fewer re-operations required over the long term [5]. The 5-year reoperation rate for HoLEP is approximately 1–2% in experienced centres, compared to 5–8% for TURP [6].
Minimal Blood Loss
The holmium laser's inherent coagulative properties result in significantly less intraoperative bleeding compared to TURP. A 2025 multi-centre study published in Nature reported that TURP patients had a transfusion rate of 8.8% and ICU admission rate of 1.7%, compared to only 2.5% and less than 1.2% respectively for HoLEP [7].
Shorter Hospital Stay and Catheterisation Time
Most HoLEP patients have their urinary catheter removed within 24 hours, and many can be discharged on the same day of surgery. In a prospective trial of 190 patients, 90% had their Foley catheter removed and were discharged on the same day [8]. This contrasts sharply with TURP, which typically requires 2–3 days of catheterisation and 2–4 days of hospitalisation.
No Risk of TURP Syndrome
Because HoLEP uses normal saline for irrigation rather than the hypotonic solutions required for monopolar TURP, there is no risk of TURP syndrome — a potentially life-threatening condition caused by absorption of large volumes of hypotonic fluid leading to severe dilutional hyponatraemia [1].
Tissue Available for Pathological Examination
Unlike laser vaporisation techniques that destroy tissue, HoLEP provides intact tissue specimens for histological analysis. Approximately 8% of HoLEP specimens reveal incidental prostate cancer, providing valuable diagnostic information [9].
Clinical Evidence: Outcomes from 3,000 Patients
A landmark 2024 prospective registry study by Lee et al., involving 3,000 patients at a single institution, provides the most comprehensive evidence for HoLEP outcomes to date [10]:
| Parameter | Baseline | 6 Months Post-HoLEP | Improvement |
|---|---|---|---|
| IPSS (symptom score) | 19.3 ± 7.7 | 6.6 ± 5.8 | 66% reduction |
| Qmax (peak flow rate) | 9.4 mL/s | 22.2 mL/s | 136% increase |
| Catheterisation time | — | 1.0 day | — |
| Operation time | — | 60.7 ± 31.5 min | — |
The complication profile was remarkably favourable:
| Complication | Rate |
|---|---|
| Blood transfusion | 0.6% |
| Re-catheterisation (within 2 weeks) | 3.7% |
| Bladder neck contracture (6 months) | 0.5% |
| Urethral stricture (6 months) | 1.0% |
| Stress urinary incontinence (6 months) | 1.9% (mostly mild) |
| Urgency urinary incontinence (6 months) | 1.3% (mostly mild) |
These results demonstrate that HoLEP delivers dramatic symptomatic improvement with an exceptionally low complication rate, even in a large, real-world patient cohort.
HoLEP vs. TURP: A Comprehensive Comparison
| Feature | HoLEP | TURP |
|---|---|---|
| Prostate size limit | No limit (any size) | Best for < 80 mL |
| Tissue removal method | Anatomical enucleation | Chip resection |
| Blood transfusion rate | 0.6–2.5% | 5–8.8% |
| Catheter duration | 1 day (often same-day removal) | 2–3 days |
| Hospital stay | 1 day (often same-day discharge) | 2–4 days |
| TURP syndrome risk | None (uses normal saline) | Present (monopolar) |
| 5-year reoperation rate | 1–2% (experienced centres) | 5–8% |
| Tissue for pathology | Yes (complete specimen) | Partial chips only |
| Anticoagulation patients | Safe option | Higher bleeding risk |
| Learning curve | 50+ cases for proficiency | Shorter |
The HoLEP Procedure: Step by Step
Preoperative Assessment
Before undergoing HoLEP, patients receive a thorough evaluation including:
- International Prostate Symptom Score (IPSS) questionnaire to quantify symptom severity
- Uroflowmetry to measure peak urinary flow rate (Qmax)
- Post-void residual (PVR) measurement via ultrasound
- Prostate volume assessment using transrectal ultrasound (TRUS) or MRI
- PSA testing to rule out prostate cancer
- Flexible cystoscopy for patients with severe symptoms or haematuria
The Surgery
The procedure is performed under general or spinal anaesthesia with the patient in the dorsal lithotomy position. The key steps include:
Step 1 — Urethral Access: A continuous-flow resectoscope (26–28 French) is introduced through the urethra after gentle dilation with Van Buren sounds.
Step 2 — Landmark Identification: The surgeon identifies key anatomical landmarks including the verumontanum, bladder neck, and ureteral orifices.
Step 3 — Incision: Using the holmium laser at 2 Joules and 40–50 Hz, incisions are made at the 5 and 7 o'clock positions from the bladder neck to the verumontanum, reaching the surgical capsule.
Step 4 — Enucleation: The prostatic lobes are systematically enucleated from the surgical capsule in a retrograde fashion (apex to bladder neck), following the natural tissue plane. The median lobe is typically enucleated first, followed by the lateral lobes. The enucleated tissue is pushed into the bladder.
Step 5 — Haemostasis: The prostatic fossa is carefully inspected, and any bleeding vessels are coagulated using the defocused laser at reduced frequency (20–30 Hz).
Step 6 — Morcellation: A nephroscope and morcellation device are introduced to fragment and remove the enucleated tissue from the bladder. The bladder is kept full during morcellation to maintain safe distance from the bladder wall.
Step 7 — Final Inspection: The prostatic fossa, bladder, and ureteral orifices are inspected one final time before placing a Foley catheter.
Postoperative Recovery
Recovery after HoLEP is remarkably swift. Most patients experience the following timeline:
- Day 0 (surgery day): Catheter may be removed the same evening if haematuria is acceptable; many patients are discharged the same day
- Day 1: If not discharged on day 0, catheter removal and discharge typically occur
- Week 1–2: Mild urinary frequency and urgency are common as the prostatic fossa heals; light activities can be resumed
- Week 4–6: Most patients return to full normal activities; significant symptomatic improvement is already evident
- Month 3–6: Maximum benefit is achieved with sustained improvement in IPSS and Qmax
Who Is a Candidate for HoLEP?
HoLEP is suitable for virtually all men with symptomatic BPH who have failed medical therapy. Particularly good candidates include:
- Men with large prostates (> 80 mL) where TURP would be challenging
- Patients on anticoagulation therapy who cannot safely stop their blood thinners, as HoLEP's coagulative properties provide superior haemostasis
- Patients with urinary retention requiring catheter drainage
- Men with recurrent urinary tract infections or bladder stones secondary to BPH
- Patients who have failed previous BPH procedures (TURP, laser vaporisation, Urolift, etc.)
The only significant considerations are the patient's ability to tolerate general or spinal anaesthesia and the availability of a surgeon experienced in the technique.
Dr. Chui Ka Lun: Pioneering HoLEP in Hong Kong
Dr. Chui Ka Lun (崔家倫醫生) is a Specialist in Urology who holds the qualifications of MBBS (HKU), FRCSEd, FCSHK, FRCSEd(Urol), and FHKAM (Surgery). He is recognised as a pioneer who introduced three advanced urological procedures to the Hong Kong urology community: HoLEP (Holmium Laser Enucleation of the Prostate), transperineal prostate biopsy, and transurethral seminal vesiculoscopy.
Beyond his clinical practice, Dr. Chui is deeply committed to community service and medical advancement. He serves as a National Security Education mentor and has actively supported District Council and Legislative Council election campaigns. He spearheaded the charitable joint replacement programme "Walking with You, Stand Up Together" (「與你同行站起來」) through the HKFTU Specialist Clinic, providing subsidised joint replacement surgery to patients in need.
Dr. Chui has also been instrumental in promoting cross-border medical collaboration. He has led delegations of Hong Kong doctors to visit hospitals in mainland China, fostering understanding of the nation's healthcare development and encouraging Hong Kong physicians to explore multi-site practice opportunities within the Greater Bay Area (GBA). His vision of integrating Hong Kong's medical expertise into the broader GBA healthcare ecosystem reflects his commitment to expanding access to quality medical care across the region.
Frequently Asked Questions
Q: How long does the HoLEP procedure take? A: The average operative time is approximately 60 minutes, though this varies depending on prostate size and surgeon experience. For very large prostates (> 150 mL), the procedure may take 90–120 minutes.
Q: Is HoLEP painful? A: The procedure is performed under anaesthesia, so patients feel no pain during surgery. Postoperatively, most patients experience only mild discomfort that is well-controlled with standard pain medication. Many patients report less pain compared to TURP.
Q: When can I return to normal activities? A: Most patients can resume light daily activities within 1–2 weeks and return to full activity, including exercise, within 4–6 weeks.
Q: Will HoLEP affect my sexual function? A: HoLEP generally preserves erectile function. Long-term studies show that erectile function outcomes are comparable to or better than TURP. However, retrograde ejaculation (dry orgasm) occurs in approximately 75% of patients, which is similar to other BPH surgeries. This does not affect the sensation of orgasm.
Q: Is HoLEP safe for patients on blood thinners? A: Yes. HoLEP is one of the safest surgical options for patients who cannot stop anticoagulation therapy. The holmium laser's coagulative properties provide excellent haemostasis, significantly reducing bleeding risk compared to TURP.
Q: How long do the results last? A: HoLEP provides the most durable results of any BPH surgery. Long-term studies show sustained symptom relief for over 10 years, with reoperation rates of only 1–2% at 5 years in experienced centres.
Why Choose Hong Kong for HoLEP Surgery?
Hong Kong offers a unique combination of advantages for international patients seeking HoLEP surgery:
- World-class medical infrastructure with internationally accredited hospitals
- Experienced urologists trained in the latest laser enucleation techniques
- Bilingual medical staff fluent in English, Cantonese, and Mandarin
- Visa-free entry for GCC nationals, simplifying travel arrangements
- Muslim-friendly environment with halal dining options and prayer facilities
- Strategic location with direct flights from major GCC cities (Dubai, Riyadh, Doha, Kuwait City)
- Competitive pricing compared to Western countries, with transparent fee structures
References
- Badreldin AM, Ghanem K, Leslie SW, Soon-Sutton TL. Laser Enucleation of the Prostate (HoLEP and ThuLEP). StatPearls. Updated January 19, 2025. NCBI Bookshelf.
- Gilling PJ, Wilson LC, King CJ, et al. Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int. 2012;109(3):408-411.
- European Association of Urology. EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO). 2024.
- American Urological Association. Benign Prostatic Hyperplasia (BPH) Guideline. 2024.
- Gilling PJ, et al. Long-term results of a randomized trial comparing HoLEP and TURP: results at 7 years. BJU Int. 2012;109(3):408-411.
- Comprehensive 2023 study of reoperation rates across 130,106 patients from 119 studies comparing BPH surgical procedures.
- Pyrgidis N, et al. Perioperative outcomes of HoLEP, ThuLEP, and TURP in large prostates. Prostate Cancer Prostatic Dis. 2025.
- Same-day discharge prospective trial of 190 HoLEP patients. J Urol. 2024.
- Badreldin AM, et al. Tissue available for pathological evaluation after laser enucleation. StatPearls. 2025.
- Lee H, So S, Cho MC, et al. Clinical outcomes of holmium laser enucleation of the prostate: A large prospective registry-based patient cohort study. Investig Clin Urol. 2024;65(4):361-367.
