What are the benefits and risks of prostate enucleation (surgical removal of prostate tissue) with a holmium laser (HoLEP) compared to other prostate surgeries?

Key messages

• HoLEP and the standard prostate operation (TURP) may relieve urinary symptoms and improve quality of life to a similar degree and with similar serious complications in the first year after surgery.

• HoLEP probably lowers the need for a blood transfusion compared to TURP, prostatectomy (removal of the prostate) and laser ablation (using a laser beam to destroy prostate tissue). For every 1000 men treated, about 36 fewer would need one.

• We don’t have enough evidence yet to say whether HoLEP is better for very large prostates or for people who take certain blood-thinning medicines.

What is benign prostatic hyperplasia?

The prostate is a small gland found only in men. It’s a non-cancerous condition where the prostate grows bigger as men get older, which can block urine flow. This is like a pipe getting narrower and harder to pee through.

How is benign prostatic hyperplasia treated?

Treatments include lifestyle changes, medicines, and surgeries. For a long time, the most common surgery was called transurethral resection of the prostate (TURP). In TURP, a doctor uses a small tool inserted through the urethra (the pee tube) to scrape away the extra prostate tissue. Today, doctors also use lasers to do this job. One type of laser surgery is called HoLEP.

What did we want to find out?

We wanted to know how HoLEP compares with other surgical options in terms of relief of symptoms, quality of life, and safety (unwanted effects).

What did we do?

We searched for studies where doctors compared HoLEP with other prostate surgeries. We looked at how well each surgery worked, how safe it was, and how quickly men recovered. We then summed all the results and assessed the reliability of each study.

What did we find?

We found 52 studies involving 6242 men who had prostate surgery. This summary focuses on studies comparing HoLEP with TURP — the standard prostate operation — in the first year after surgery, because this is the comparison the one most relevant to men choosing between operations. The average age of the men ranged from 65 to 74 years, and the average prostate size in the studies ranged from 30 cc to 142 cc. Studies took place in 11 countries.

• Symptoms and quality of life: HoLEP may relieve urinary symptoms (14 studies, 1666 people) and improve quality of life (6 studies, 876 people) to a similar extent as TURP. Any difference we found was too small to matter to men.

• Serious complications: HoLEP may have similar serious complications (10 studies, 1147 people) compared with TURP.

• Repeat surgery and erectile function: These are probably similar after both operations.

• Ejaculation: No study reported what happened to ejaculation after either operation, even though this matters a great deal to many men.

• Blood transfusion: HoLEP probably lowers the chance of needing a blood transfusion compared to most other surgeries. About 44 in every 1000 men need a transfusion after TURP, compared with about 8 in every 1000 after HoLEP (15 studies, 1755 people).

• We also compared HoLEP with other laser operations, other enucleation techniques, and open surgery, and examined results beyond one year. These results are reported in the full review.

What are the limitations?

• Study quality: Most studies had design problems — for example, it is impossible to mask surgeons and very challenging to mask patients as to which operation was performed, which can affect how results are measured and reported. Only a few studies had pre-registered plans, so some results may have been selectively reported. For these reasons, our confidence in many findings is low or very low.

• Short follow-up: Most studies only followed patients for up to 12 months. We do not know whether the benefits of HoLEP hold up over longer periods, or whether repeat surgery rates differ substantially in the long run.

• No study reported on ejaculatory function for any comparison. Given that roughly three out of four men experience retrograde ejaculation (dry orgasm) after HoLEP, this is an important gap. Data on urinary leakage (incontinence) after surgery were also not consistently reported.

• Surgeon experience: Most surgeons in the included studies were highly experienced with HoLEP. Actual results may differ where surgeons are still learning: complication rates continue to fall with experience, settling only after about 350 operations.

• Limited evidence for certain patient groups: We could not perform the planned analyses for men with very large prostates (≥ 80 mL) or those taking blood-thinning medicines, because too few studies included these patients. These are precisely the groups in whom HoLEP may offer the greatest advantage, so this is a particularly important gap.

• Fewer studies for some comparisons: Most evidence compared HoLEP with TURP; we are less certain about comparisons with laser ablation, alternative enucleation techniques, or open surgery.

How up-to-date is this review?

This review is up-to-date to April 08, 2026.