December 3, 2018/Urology & Nephrology/Urology

Why More Urologists Should Consider HoLEP for Treating BPH

Technique offers many benefits for patients with very large prostates


Despite many factors in its favor, holmium laser enucleation of the prostate (HoLEP) to treat benign prostatic hyperplasia (BPH) has not achieved widespread popularity in the U.S.


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Smita De, MD, PhD, a Cleveland Clinic urologist who performs HoLEP, advises urologists not be so quick to rule out this treatment option.

The many benefits in its HoLEP’s favor

“In comparison with several other BPH procedures, the benefits of HoLEP include a shorter hospital stay, shorter time needed for catheterization and decreased bleeding risk,” Dr. De explains.

With HoLEP, the need for retreatment is much less of a problem than it is for patients who have had certain other noninvasive treatments. “The retreatment rate for HoLEP is typically less than 1-2%,” she notes. In comparison, the retreatment rate with TURP is between 6 and 18%.

Another advantage of HoLEP is that it can effectively treat very large prostates. “A lot of procedures, especially the newer ones like UroLift® and some other minimally invasive procedures, don’t necessarily work well on very large prostates,” Dr. De says.


HoLEP, on the other hand, is a size-independent procedure. HoLEP approaches the task of treating BPH from a different direction than other noninvasive treatments. “Most other procedures for BPH work from the inside out,” she says. “They are carving out the middle of the prostate Roto-Rooter-style, like TURP, or ablating or lasering it from the inside.

“With HoLEP, we are working around the entire outside of the organ,” Dr. De says. “We are at the outer edges of the capsule trying to remove every bit. We are often able to get more tissue than those other procedures that work from the inside.”

So why isn’t HoLEP more widely used here?

Newness is not the issue, according to Dr. De. “HoLEP is not a new procedure; it’s been around since the 1990s. Dr. De suggests the following factors may be working against HoLEP:

  • Training time: “HoLEP is thought to have more of a learning curve than a lot of other procedures for BPH. They say it takes 20 to 50 procedures to become proficient,” says Dr. De.
    Opportunities to learn HoLEP are more readily available in some countries. In the U.S., there are not as many medical centers offering the procedure. If a urologist doesn’t learn to do HoLEP during either residency or fellowship, the barriers to him or her mastering the procedure are high.
    “People who are out in practice may go take a course,” Dr. De says, “but then they need to observe and practice with someone doing a lot of the procedures.” Such observational time, she explains, allows the learner to experience ways to troubleshoot and handle tough cases.
  • Lack of commercial champion: “There is no one company behind HoLEP,” Dr. De says. “No one is selling this procedure. It’s not a device. It’s simply a technique using many instruments we already have.”
    Meanwhile, some manufacturers actively promote certain other approaches to treating BPH that involve their specific devices.
  • An instrumentation issue: “We use a high-powered holmium laser to perform HoLEP, as well as a morcellator,” Dr. De says. The morcellator instrument is not used in any other area of urology, she explains. It’s not needed for kidney stones or other procedures, and it requires additional training.
    Accordingly, the instrument may not rank high on the list of devices that a hospital administrator decides to purchase. “They may think, ‘Why should I buy a device that one surgeon uses versus a device that 20 use?’”

No procedure is perfect

HoLEP also may present some disadvantages. “HoLEP might be a longer procedure than some of the others available, so the patient must be under anesthesia longer,” Dr. De notes.


However, at the end of the day, Dr. De is a staunch proponent of HoLEP. At the same time, she says, “I don’t think that it’s a one-size-fits-all situation when it comes to choosing a procedure for treating BPH. Different procedures are appropriate in different situations, and for different patients.

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