HoLEP for an enlarged prostate: laser surgery explained, with risks and recovery

As the prostate grows with age it can squeeze the urethra and cause a weak stream, hesitancy, dribbling, getting up at night, or in some men a blocked bladder. The NHS describes TURP as the most common operation for an enlarged prostate and notes that lasers, steam, water jets and implants are also used for some men.

HoLEP is generally offered when symptoms are bothersome and tablets have not worked or are not tolerated, or when there has been retention, bladder stones, repeated infections or bleeding from the prostate. It is not the right operation for every symptom of the waterworks. Overactive bladder, nerve problems, a narrowing in the urethra, or prostate cancer all need different assessments, and a urologist will test for them first.

A trust leaflet lists the alternatives as monitoring with lifestyle changes, medicines that relax the bladder neck or shrink the prostate, a catheter used intermittently or long term, minimally invasive options such as UroLift, Rezum, iTind and Aquablation, prostate artery embolisation, TURP and open surgery.

Each has trade-offs. Some preserve ejaculation more often but may not suit a large gland. HoLEP can be used for prostates of many sizes, and that flexibility is one reason it is offered. Not every option is available at every NHS hospital, as the NHS itself notes about alternatives to TURP.

Before surgery you will usually have a symptom score, a urine test, blood tests including a PSA, and often a flow-rate test and bladder scan. A pre-assessment clinic checks your fitness and, in some trusts, screens for MRSA. A leaflet describes consent, anaesthetic review and compression stockings to lower clot risk.

Tell the team about blood thinners such as warfarin, aspirin or newer anticoagulants, because they need a plan. You will be asked to fast for several hours before the operation, with one leaflet giving six hours. Pelvic floor exercises started beforehand can help with leakage afterwards, and one trust recommends an app-guided routine.

You usually go in on the morning of surgery. Under general or spinal anaesthetic, a telescope is passed along the urethra. The laser separates the inner, obstructing tissue from its outer capsule in large pieces, which are pushed into the bladder and then broken up and removed with a device called a morcellator. One leaflet gives 45 to 90 minutes depending on prostate size, which is a trust figure rather than a universal one.

A catheter is placed at the end, often with fluid running through it to clear bleeding. Many men go home the same day with the catheter in, but some stay overnight, so a bag packed for one night is sensible. Your team will explain how to look after the catheter and when it comes out.

Common effects are burning when passing urine, blood in the urine, urgency and frequency for a while, and temporary leakage, especially when coughing or lifting, in the first weeks. Retrograde ejaculation, where semen passes back into the bladder, is expected in most men; it is harmless medically but means little or no semen emerges. Blood-stained semen can appear for weeks.

Less common problems include infection, a return to retention needing the catheter again, a scar narrowing in the urethra, and erectile difficulty. Long-term incontinence is uncommon. Leaflets quote different percentages for these, and one trust page gives figures such as about 1 in 100 for erectile problems in men who had none before, so ask your own surgeon for the numbers they use. Rare risks include bleeding needing a transfusion and bladder injury.

Leaflets describe feeling tired for a week or two, light bleeding for a few weeks with a possible flare-up in the second to fourth week, and urgency that settles. Drinking plenty of fluids keeps bleeding down. Avoid heavy lifting and straining; trusts suggest two to four weeks. Sex can restart when you are comfortable, one trust giving around three to four weeks. A review at about three months is described.

Our recovery timeline page sets this out phase by phase. Remember that the advice differs between hospitals, so what you are given on discharge takes priority.

Contact the ward or your GP if bleeding is heavy or lasts beyond a day or two, if you cannot pass urine, if the catheter stops draining, or if you develop fever or burning. Go to A&E or call 999 for severe bleeding with clots, or if you feel faint or very unwell.

Good questions: How many HoLEPs does the surgeon do? Is it day case here? How long will the catheter stay? What is the chance of dry ejaculation, and could a different operation protect it? In the NHS the wait and the availability of laser equipment vary by area, and private hospitals tend to offer faster listing, with the surgeon and fee itemised in advance.