Written by Mr Jai Seth, Consultant Urological Surgeon
Specialist in bladder, prostate and urinary health, London · Full biography · Publications
If you are a man over 50 experiencing difficulty urinating, a weak stream, or frequent trips to the toilet, you may have an enlarged prostate. This condition, known as benign prostatic hyperplasia (BPH), is extremely common and affects the majority of men as they age. The good news is that there are highly effective treatments available, including HoLEP – widely regarded as the gold standard for larger prostates.
What Is Benign Prostatic Hyperplasia (BPH)?
BPH is a non-cancerous enlargement of the prostate gland. The prostate surrounds the urethra (the tube that carries urine from the bladder), so when it enlarges, it can squeeze the urethra and obstruct urine flow. BPH is not prostate cancer and does not increase your risk of developing cancer.
Common Symptoms of an Enlarged Prostate
Weak Urine Stream: The flow of urine is slower and less forceful than it used to be.
Difficulty Starting: You may need to strain or wait before urine begins to flow.
Stopping and Starting: The stream may be intermittent rather than continuous.
Incomplete Emptying: A feeling that the bladder has not fully emptied after urinating.
Frequent Urination: Needing to urinate more often, especially during the day.
Nocturia: Waking up multiple times during the night to urinate.
Urgency: A sudden, strong need to urinate that is difficult to defer.
Dribbling: Urine continues to dribble after you have finished urinating.
Treatment Options for BPH
Watchful Waiting: For mild symptoms, monitoring without active treatment may be appropriate.
Lifestyle Modifications: Reducing caffeine and alcohol, avoiding fluids before bed, and double voiding can help manage symptoms.
Medications: Alpha-blockers relax the prostate muscles to improve flow, while 5-alpha reductase inhibitors can shrink the prostate over time.
Minimally Invasive Therapies: Procedures like Rezum (water vapour therapy) and UroLift can provide relief with minimal downtime.
Surgical Options: For moderate to large prostates, surgery offers the most definitive treatment.
What Is HoLEP?
HoLEP stands for Holmium Laser Enucleation of the Prostate. It is a minimally invasive surgical procedure that uses a laser to remove the obstructing prostate tissue. Unlike traditional TURP (transurethral resection of the prostate), HoLEP removes the entire adenoma (the enlarged portion) rather than just shaving it down.
Why Is HoLEP Considered the Gold Standard?
Effective for All Prostate Sizes: While TURP is limited to smaller prostates, HoLEP can treat prostates of any size, including very large ones that would otherwise require open surgery.
Durable Results: Because HoLEP removes the entire adenoma, the risk of the prostate regrowing and symptoms returning is very low. Studies show excellent results lasting 10 years or more.
Less Blood Loss: The laser seals blood vessels as it works, resulting in significantly less bleeding compared to traditional surgery.
Shorter Catheter Time: Most patients have their catheter removed within 24 hours after surgery.
Faster Recovery: Many patients return to normal activities within two weeks.
Tissue Available for Analysis: The removed tissue can be examined for any signs of prostate cancer, providing additional peace of mind.
What to Expect with HoLEP
The procedure is performed under general or spinal anaesthesia. A telescope is passed through the urethra, and the laser is used to carefully separate the enlarged prostate tissue from the surrounding capsule. The tissue is then pushed into the bladder, morcellated (broken into small pieces), and removed. Most patients stay in hospital for one night and go home the following day.
Success Rates
HoLEP has outstanding success rates. Studies consistently show: - Significant improvement in urine flow rates - Marked reduction in symptoms scores - High patient satisfaction rates - Low retreatment rates (less than 2% at 10 years)
Is HoLEP Right for You?
HoLEP is particularly suitable for men with: - Moderate to large prostates - Symptoms that have not responded adequately to medications - Urinary retention (inability to pass urine) - Recurrent urinary tract infections due to incomplete bladder emptying - Bladder stones caused by obstruction
Seeking assessment
Urinary symptoms that affect sleep or daily life are worth investigating rather than accepting as a feature of age. A GP appointment is the starting point: a brief history, a PSA blood test where appropriate, and a physical examination usually narrow things down, and referral to a urologist — NHS or private — follows where specialist assessment is needed. Ring NHS 111 or ask for a same-day GP appointment if you cannot pass urine at all, see visible blood in your urine, or experience pain on passing urine.
References
- Gravas S, et al. EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO). European Association of Urology. 2023.
- Kuntz RM, et al. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol. 2008 Jan;53(1):160-6.
- Ahyai SA, et al. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. Eur Urol. 2010 Sep;58(3):384-97.
- Wong K, Kinsella N, Seth J, et al. Comparing UroLift and standard transurethral resection of prostate ahead of radiotherapy in men with urinary symptoms secondary to prostate enlargement in Southwest London and North Cumbria (CO-STAR): a study protocol for a randomised feasibility study. BMJ Open. 2023 Oct;13(10):e076621.