Honest breakdown of HoLEP for enlarged prostate (BPH)

I'm Prof. Matteo Ferro, a urologist based in Milan. I get a lot of questions from patients about BPH once medication stops being enough, so I wanted to write something clear and non-promotional about one of the options I perform regularly: HoLEP (Holmium Laser Enucleation of the Prostate).

What it is, simply:
Picture the prostate like an orange. In BPH, the "pulp" (the inner tissue) grows and squeezes the urethra, the tube urine passes through. HoLEP uses a holmium laser to separate that overgrown tissue from the outer capsule — like a finger working between the pulp and the peel. Once it's freed, it's pushed into the bladder, broken into small pieces with a morcellator, and suctioned out. This is done entirely through the natural urinary passage — no external incision.

Why patients ask about it specifically:

• It works regardless of prostate size. Historically, very large prostates (80-100g+) meant open surgery. HoLEP removes that limitation.
• Because it's a laser, bleeding vessels seal as it cuts — so bleeding risk is low, which matters a lot for patients on blood thinners (always under close monitoring).
• Since the tissue is removed intact rather than vaporized, it can be sent to pathology — a real advantage for long-term monitoring.
• Recovery is fast. Catheter typically comes out in 24-48 hours.
• Because so much tissue is removed, regrowth requiring another procedure is uncommon compared to older techniques.

What it doesn't do:
It's not magic, and it's not without trade-offs. Most patients experience retrograde ejaculation afterward (semen enters the bladder rather than exiting) — this is common with HoLEP given how thorough the tissue removal is. Erectile function is generally unaffected. If fertility or ejaculatory sensation matters to you, that's a conversation worth having before deciding between HoLEP and less invasive options like Rezum (steam therapy — quick, usually preserves ejaculation, but better suited to small-to-medium prostates) or the older standard, TURP.

When I'd tell someone to stop waiting:
If you're getting up 3-4 times a night, your stream has weakened significantly, or your usual medication just isn't working anymore: don't wait for a full urinary blockage. Earlier evaluation generally means a less aggressive treatment path and better outcomes!