Written by Mr Jai Seth, BSc(Hons) MBBS MRCS MSc(Urol) MD(Res) FRCS(Urol)
Consultant Urological Surgeon · Last updated:
In short
- Treats
- An enlarged prostate that is blocking urine flow, whatever its size
- Who it suits
- Men whose tablets have not worked, or who are in retention
- Anaesthetic and stay
- General or spinal; usually one night in hospital
- Catheter
- Out within one to two days
- Back to normal
- A few weeks; desk work sooner than physical work
- Sex afterwards
- Erections and orgasm are not generally affected; semen is no longer released in about nine men in ten
- Where
- NHS at St George's and Kingston; privately at Nuffield Health Parkside
- Right for you?
- Depends on prostate size, how the bladder is working, and what matters most to you; worked out at consultation
Because the tissue is peeled out rather than shaved down, the obstruction is cleared completely, and because the laser seals blood vessels as it works, bleeding is lower than with the older resection methods. Those two things are what let HoLEP be used on prostates of any size, including very large glands that would once have needed open surgery.
Mr Seth leads the HoLEP programmes at St George's and Kingston Hospitals and offers the procedure privately at Nuffield Health Parkside in Wimbledon. NICE says HoLEP should be done at a centre that specialises in it, or by a surgeon being mentored by one that does, and the European Association of Urology guideline finds that the surgeon's experience has more bearing on the complication rate than anything else about the operation. In practice that means asking how often your surgeon does it.
Who is it suitable for?
- Urinary symptoms from an enlarged prostate that are moderate or severe and have not been controlled by tablets, or where the tablets cause side effects you would rather not live with.
- A prostate of any size. HoLEP is the endoscopic option that suits very large glands (over 80 g), where the traditional alternative has been open surgery through an abdominal incision.
- Retention of urine, including men who are dependent on a catheter. HoLEP has a good record of getting these men passing urine on their own again.
- Complications of obstruction: recurrent urine infections, bladder stones, repeated retention, or kidney function affected by back-pressure from the bladder.
- Men who take blood-thinning medication. Because the laser seals vessels as it cuts, HoLEP is often the operation considered when stopping anticoagulants carries its own risk. Whether and how to pause them is decided case by case with the doctor who prescribes them.
- HoLEP is usually not the right choice for men whose symptoms are mild and not affecting daily life, or for men for whom keeping normal ejaculation is the priority, since about nine in ten no longer release semen afterwards. UroLift and Rezum are the options to discuss in that situation.
- The operation is available on the NHS at centres that offer it, including the St George's and Kingston programmes Mr Seth leads, and privately at Nuffield Health Parkside with a shorter wait. Whether surgery is right for you at all, and which operation, is decided after assessment.
How does it work?
- The operation is done under a general or a spinal anaesthetic. A telescope is passed along the urethra to the prostate; there is no cut in the skin.
- The prostate has two parts: an outer capsule and an inner adenoma that has grown over the years and squeezes the urethra. The holmium laser is used to find the plane between the two and free the adenoma from the capsule, lobe by lobe, in the way a segment comes away from an orange.
- The freed lobes are pushed into the bladder. An instrument called a morcellator is then passed through the telescope to chop the tissue into small pieces and suck them out.
- The laser coagulates blood vessels as it cuts, so the cavity left behind bleeds less than after a resection. Any remaining bleeding points are sealed with the laser before the telescope is withdrawn.
- All of the removed tissue goes to the pathology laboratory. Occasionally this reveals prostate cancer that was not suspected beforehand, which would then be discussed with you at follow-up.
- A catheter is placed at the end of the operation, with fluid run through it for a short while to wash out any clots. Operating time is usually around two hours and depends on the size of the prostate.
What to expect
Before the procedure
- Assessment before surgery establishes how large the prostate is (by examination and by ultrasound or MRI), how well the bladder empties, and whether the bladder muscle rather than the prostate is driving the symptoms. A flow test and a bladder scan are routine; urodynamic studies are added where the picture is unclear.
- A PSA blood test and a urine test are checked. HoLEP treats benign enlargement, so anything that raises a question about cancer is investigated first.
- Pre-operative assessment covers fitness for anaesthesia, with blood tests and an ECG where indicated.
- Blood thinners are reviewed in advance. Many men can have HoLEP without a long interruption to anticoagulation, but the plan depends on the drug and the reason you take it, and it is agreed with you before admission. Do not stop or change these medicines without instructions.
- Standard fasting applies: no food for six hours and no clear fluids for two hours before the anaesthetic. Antibiotics are given at the start of the operation.
On the day
- You are admitted on the day of surgery. The anaesthetist discusses a general or a spinal anaesthetic with you, and you may be given stockings and a small injection to lower the risk of blood clots.
- After the operation you wake with a catheter in place and fluid running through it. The drainage is pink at first and clears over the following hours.
- Most men stay one night. Some go home the same day, depending on the size of the prostate and how quickly the bleeding settles.
- The catheter usually comes out within one to two days. Passing urine is uncomfortable at first and more frequent than normal; simple painkillers help and it eases over a few days.
- A minority of men cannot pass urine when the catheter is first removed, because of swelling. If that happens a catheter goes back in for about a week, and the second removal is successful in almost every case.
Recovery and aftercare
- Drink about twice your usual amount of fluid for the first day or two to flush the bladder and lower the risk of infection.
- Blood in the urine comes and goes for a few days, and around one man in five has a further bleed two to three weeks after surgery when the scabs in the prostate cavity separate. More fluid usually settles it; if it does not, contact your GP. Heavy bleeding, clots, or suddenly being unable to pass urine need same-day medical attention.
- Some leakage is common in the early weeks. HoLEP removes a lot of tissue and the sphincter and pelvic floor take time to adjust. Pelvic floor exercises speed this up, and for most men control returns over a short period.
- Burning and urgency ease over the first week or two. Avoid heavy lifting, vigorous exercise and long drives until the bleeding has fully settled, which for most men means a few weeks.
- You can return to work when you are comfortable. Desk-based work is usually possible sooner than physical work.
- Follow-up is at about six weeks, with a flow test and a symptom score, and the pathology result from the removed tissue is reviewed with you.
Outcomes and evidence
- NICE clinical guideline CG97 names three standard operations for symptoms caused by prostate enlargement: TURP, transurethral vaporisation and HoLEP. It says open prostatectomy should only be offered as an alternative to those three for prostates estimated at over 80 g, and that HoLEP should be performed at a centre specialising in the technique or with mentorship in place.
- The European Association of Urology guideline (2026 edition) gives a strong recommendation for HoLEP as an alternative to TURP or open prostatectomy. Its evidence summary rates HoLEP as having similar mid- and long-term efficacy to TURP, a longer operating time, and a more favourable perioperative profile: shorter catheter and hospital times and less blood loss.
- A randomised trial of HoLEP against open prostatectomy for prostates over 100 g (Kuntz et al., European Urology 2008) found the two operations equally effective at five years, with less bleeding and a shorter hospital stay after HoLEP. A six-year series (Gilling et al., European Urology 2008) shows the improvement in flow and symptoms holding up over that time.
- Meta-analyses of transurethral procedures (Ahyai et al. 2010; Cornu et al. 2015, both European Urology) support the same picture: enucleation removes more tissue than resection, fewer men need a repeat operation, and the rate of urethral stricture is no higher.
- Mr Seth leads the HoLEP programmes at St George's and Kingston Hospitals. His published research on benign prostate enlargement includes the CO-STAR feasibility trial (Wong K, Kinsella N, Seth J, et al., BMJ Open 2023), which compares UroLift with TURP in men who need radiotherapy for prostate cancer and have urinary symptoms from an enlarged prostate.
Risks and complications
- Almost everyone has some burning, bleeding and frequency in the first days. These are expected and settle.
- Erections and the sensation of orgasm are not generally affected. What changes, for about nine men in ten, is ejaculation: semen passes back into the bladder at orgasm instead of out, so little or nothing is produced. The change is permanent, which is why men who want to keep normal ejaculation are usually offered UroLift or Rezum instead.
- Blood in the urine continuing for several days affects between one in two and one in ten men. Bleeding severe enough to need a transfusion or a return to theatre is uncommon, between one in 50 and one in 250.
- Most men keep full control of their urine from the start. Between one in 10 and one in 50 have some leakage in the early weeks; it improves with pelvic floor exercises and settles for most within weeks to a few months. Leakage that persists beyond that is uncommon and can be treated.
- Symptoms not fully relieved by the operation, usually because the bladder muscle rather than the prostate was the main problem, affect between one in 50 and one in 250 men. This is why the assessment before surgery looks at the bladder as well as the prostate.
- Urethral stricture, a narrowing from scar tissue, occurs in a small minority and is no more frequent than after TURP. Anaesthetic and cardiovascular complications are between one in 50 and one in 250 and depend on your general health; the anaesthetist estimates your individual risk. Erections are not generally reported to change after HoLEP. The full list, and how each item applies to you, is part of the consultation.
- Set against these, most men get a lasting improvement in flow and symptoms, the result holds up over at least six years in published series, a repeat operation is less likely than after TURP, and the operation suits men on blood thinners because the laser seals vessels as it cuts.
- Your own risk depends on things that are measured before surgery: prostate size (larger glands mean a longer operation), how well the bladder muscle works (a weak bladder is the usual reason symptoms are not fully relieved), your general health for the anaesthetic, and the experience of the surgeon, which the EAU guideline identifies as the main influence on complication rates. The pre-operative assessment is where those are weighed for you.
How does it compare to alternatives?
TURP
The established resection operation. Equivalent symptom relief in the mid term; more bleeding, longer catheter time, and best suited to prostates up to around 80 g. A repeat operation is more likely over ten years than after HoLEP.
UroLift
Small implants hold the prostate lobes apart. No tissue removed, usually a day case, and ejaculation is preserved in most men. Suited to smaller prostates without a middle lobe; symptom relief is less complete and more men need further treatment.
Rezum
Steam injected into the prostate shrinks it over weeks to months. Day case, ejaculation preserved in most men. For moderate-sized prostates; not an option for retention or very large glands.
Aquablation
A robot-guided water jet removes tissue under ultrasound control, with ejaculation preserved more often than after resection. A newer technique with shorter follow-up than HoLEP; suited to moderate-to-large prostates.
Mr Seth's published research
See all publications.
Further reading
Book a consultation with Mr Jai Seth
Private appointments available at Nuffield Health Parkside Hospital, Wimbledon, and other consulting locations across London.
Book an appointment