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BackTable / Urology / Article
HoLEP Procedure Steps: Equipment Selection & Surgical Technique
Javier Prieto III • Updated Mar 8, 2025 • 32 hits
Benign prostatic hyperplasia (BPH) is a common condition with several treatment options, each varying in invasiveness and efficacy. Among these, holmium laser enucleation of the prostate (HoLEP) has gained significant attention in the urology community due to its ability to remove more prostatic tissue compared to other procedures. Recent clinical studies have highlighted the efficacy of HoLEP, making it an increasingly favored option for patients with BPH.
In this article, urologist Dr. Spencer Hiller provides a detailed review of the HoLEP procedure, detailing equipment selection and procedure steps.e.. Special attention is given to the two- and three-lobe techniques, emphasizing the advantages of initiating incisions at the apex.
This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Urology Brief
• HoLEP offers comparable success to other BPH treatments like GreenLight and TURP, but carries a higher risk of postoperative incontinence.
• In prostate cancer, HoLEP offers an aggressive approach to tissue removal. Prostatectomy after HoLEP is generally discouraged due to safety concerns. Subsequent intervention often consists of radiation therapy.
• Equipment and laser settings for HoLEP vary based on availability and operator preference, with the 550 Moses fiber laser being the most commonly used. Given the variability in laser configurations of HoLEP, collaboration and shared experiences among urologists are essential for refining techniques and improving patient outcomes.
• Pre-operative imaging and cystoscopy are essential for accurate prostate size estimation before HoLEP. Surgical technique emphasizes precision and adaptability. Key steps include enucleation of the prostate using a two- or three-lobe technique, followed by tissue removal with a morcellator via nephroscope.
Table of Contents
(1) Modality Selection: HoLEP, TURP, Aquablation or GreenLight?
(2) HoLEP Equipment Selection
(3) HoLEP Procedure Steps
Modality Selection: HoLEP, TURP, Aquablation or GreenLight?
Several techniques, including HoLEP, GreenLight laser therapy, aquablation, and transurethral resection of the prostate (TURP), have demonstrated success in treating benign prostatic hyperplasia (BPH). A key distinction among these approaches lies in the extent of prostatic tissue removal. HoLEP is notable for its ability to remove the majority of visible prostatic tissue, whereas TURP often leaves a portion of the distal tissue untouched. While the extensive tissue removal in HoLEP may make it a more effective treatment option, it is also a contributing factor to the higher incidence of postoperative incontinence in some cases.
In cancer-related cases, HoLEP procedures are often modified to adopt a more aggressive approach, as subsequent radiation therapy is frequently utilized to target any remaining pathological tissue. Typically, nearly all tissue within the transitional zone is excised, leaving only the peripheral zone of the prostate intact. Regardless of cancer presence, most HoLEP procedures prioritize comprehensive tissue removal over a conservative approach to optimize therapeutic outcomes.
The potential for further invasive interventions following HoLEP, such as prostatectomy, has sparked ongoing debate regarding its safety and efficacy. Capsular perforation and other complications are primary concerns, leading the majority of urologists to advise against prostatectomy after a HoLEP. Instead, treatments like radiation therapy are generally preferred when additional intervention is necessary. Although prostatectomy has been performed following HoLEP in some instances, it remains a less favored option due to its associated risks.
[Dr. Jose Silva]:
Because I think with other techniques, TURPS, GreenLight, Aquablation, you're always afraid of that area. It's a trade-off between being very aggressive and not having to do another BPH surgery on a person versus being less aggressive and maybe having to go back and just shave a little bit of those apical tissues. I guess that's always the question, how much to take off? When you're doing a HoLEP, you're essentially removing most of what you can see.
[Dr. Spencer Hiller]:
It would be hard to leave that distal tissue that you traditionally leave with a TURP. You rely on that anatomic plane and trying to bypass it distally to leave a little bit of that apical adenoma would be tough. There are certainly people that do it, but it would be difficult. I remember with TURP that it was, you do not go past the Vero.
The first time that I saw a HoLEP, my jaw was on the floor in terms of how far beyond it you can get sometimes. When you see it like that, you have an appreciation for why they leak immediately afterwards. I think I have found with adequate education, patient counseling, and just being truly frank with patients about it's unlikely to be permanent, but likely to be present transiently.
Most guys appreciate that and are okay with it. Some of that's just because most of the guys that I'm treating are living with a catheter at that point. They say, "If it gets me catheter free, I don't care." I certainly wouldn't say that I have nobody that leaks long-term, but it's not many if you want me to be honest. I try to keep track of that and I don't know that I've had, as far as I'm aware, anybody that's chose to move on to sphincter or sling because of their bother from the leakage.
[Dr. Jose Silva]:
In terms of other side effects, retro-ejaculation, is that something that's going to happen?
[Dr. Spencer Hiller]:
It's a certainty. I've had a couple of guys that want to try to preserve it and I've done a handful of median lobe only enucleation. I don't think they have anywhere near as good improvement in their urinary symptoms. Of the maybe 20 or so guys I've done it for, I think it has maintained antegrade ejaculation in maybe 70% or 80%.
[Dr. Jose Silva]:
So it is possible. In terms of patient selection, let's say a patient has prostate cancer or a patient prior to radiation or is on active surveillance, have you seen those types of patients?
[Dr. Spencer Hiller]:
Yes, I've been surprised the number of referrals for really big prostates on active surveillance or they've been on a chronic elevated PSA hunt and had 20 biopsies throughout their life and they're worried about the possibility of cancer or their urologist is worried about cancer. The referral is to try to minimize or get rid of prostate tissue to make this screening easier.
Now, I wouldn't recommend HoLEP for that alone, but if you add in some of the lower urinary tract symptoms that most of them have, it's been pretty successful from that standpoint. It drastically lowers their PSA and makes screening a lot easier afterwards. In the setting of prostate cancer or known prostate cancer, and they're moving on to a definitive therapy, typically radiation, it works very well in that setting.
I struggle with, and I don't know that there's an answer to this, when to start the radiation afterwards. I've typically told guys, unless they have a high risk cancer and we're really trying to push through getting treatment started, to try to wait until they're continent. Once they've stopped leaking, then they can go forward with the radiation.
[Dr. Jose Silva]:
In terms of the HoLEP technique per se, in this case, is there a way of being less aggressive, for example, in those patients trying to preserve more of the tissue and trying to preserve continents versus being a little bit more aggressive and or just let radiation take care of the tissue that is left over.
[Dr. Spencer Hiller]:
In the setting of cancer and they're planning on moving on to a definitive therapy like radiation, I actually try to be as aggressive as I can in terms of tissue removal. I think of it like a debulking of their disease. Now, HoLEP, we always talk about we're removing tissue and leaving you with just the capsule, but it's not really the capsule that we're leaving. It's the peripheral zone of the prostate. We're just removing the transitional zone.
Most of the cancers are located not in the specimen that we remove. The guys that do have cancer and I'm treating them before they get radiation, I've been surprised at how few of them have cancer in their specimen actually. Now, it's the guys that we weren't expecting to find cancer and they, come back with some low volume Gleason 6 or a low volume Gleason 7 that I'm constantly surprised at.
To answer your question, I don't really change anything. Maybe I'm a little bit more aggressive if they do have cancer to try to get out as much tissue. I don't know that that's the right thing or not. I do try to talk to guys about their concern for leakage and say somebody is really, really concerned about leakage. Then maybe I try to be a little less aggressive, but that would be true for a cancer or not cancer scenario.
[Dr. Jose Silva]:
In those patients that, WPSA, multiple biopsy, everything has been negative, then you do a HoLEP, just like the TURP or something, that patient comes back positive for cancer, and let's say he's a young guy, a candidate for Robotic-Assisted Prostatectomy. Is there a difference in terms of outcomes or ease of the surgery? Have you talked to--
[Dr. Spencer Hiller]:
Everyone that I've talked to about it may be too scared to do a prostatectomy after a HoLEP. I think there's just some concern, especially if there's maybe a capsular perforation, be it small or large, maybe there's more inflammation and the actual removal would be a little bit more difficult. I don't have any personal experience with it, and any time I have tried to move them on to, say, a prostatectomy, they've been deflected over to radiation. It'd be a good question for a high-volume prostatectomist out there.
[Dr. Jose Silva]:
Yes, I didn't know the answer, so it might be just like the ROG.
[Dr. Spencer Hiller]:
I absolutely remember during my training, prostatectomy after a TURP, there was definitely some more inflammation. It certainly wasn't impossible, and we did it. What's nice with the holmium laser is the tissue penetration is far less than what you would see from the bipolar cautery. I would expect it might be easier, but that's not the sense that I get from those that do a lot of these.
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HoLEP Equipment Selection
The equipment required for HoLEP procedures is generally standardized but may vary depending on resource availability and supply chain limitations. Commonly used items include a STORZ tower, a traditional stethoscope, and a French sheath, typically sized at 26 or 28. For the laser, the 550 Moses fiber laser is the most widely utilized due to its effectiveness and ability to deliver comparable power outcomes to larger lasers, such as the 1000 fiber laser, without compromising flow. The 550 laser is used in conjunction with a nephroscope for morcellation.
Typical laser settings for enucleation are 2 joules at 40 hertz, while settings to minimize blood loss are approximately 1.5 joules at 20 hertz. Alternatively, some urologists may prefer using a Thulium laser for enucleation, depending on their expertise and equipment availability.
Laser preferences and corresponding settings vary significantly among practitioners. Given these variations, it is critical for urologists to explore different configurations and learn from the experiences of colleagues. As HoLEP remains a relatively new procedure, ongoing investigation into optimal techniques is essential. Collaboration and the exchange of patient outcomes among urologists are crucial for refining the procedure and improving patient care.
[Dr. Jose Silva]:
In terms of the laser, side firing laser as well, or just a regular stall laser?
[Dr. Spencer Hiller]:
No, it's a regular. I use the 550 Moses fiber.
[Dr. Jose Silva]:
Going bigger for a 1,000, is there a difference or?
[Dr. Spencer Hiller]:
The reason that it's not really necessary is number one, we can achieve the necessary power outcomes with the 550, but you'd also be compromising your flow in some way. I use this Laser Ureteral Catheter to help stabilize the fiber made by Cook that I think a lot of people use that. I don't know that a 1,000 fiber would fit through there. I would worry about compromising flow in some way.
[Dr. Jose Silva]:
Yes, because I use that same technique for big stones for cystolitholapaxy, but I usually the 1,000 because it's so big, you don't need stabilizing when you're using compared to the 500. If you're doing a great job with the 500, then don't mess that around, right? In terms of bleeding, do you need to do a specific setting on the laser so it doesn't bleed?
[Dr. Spencer Hiller]:
Yes, so my settings have evolved with time. I was trained for the enucleation using a setting of 2 joules and 30 Hertz for coagulation using a setting at 2 joules and 20 Hertz, but that's on a long pulse of the laser. I've changed it a little bit where my nucleation setting, I've gone up in the power just to--
I find myself more efficient at 2 joules and 40 Hertz. Then for coagulation, I've actually gone down to 1.5 joules and 20 Hertz. There's a lot of different settings that people use out there. it's a surgery that I'm really passionate about. Of course, I followed tons of people on Twitter, X, what's posted, and there's a lot of different settings that I see used and I've tried to adapt and try new things.
That's one thing that I will say is starting in practice and building a HoLEP practice down here has required me to be very flexible with the scope I'm using, the laser I'm using, catheters, post-op management, and it's important to constantly be trying new things. I love watching videos and trying something out the next day to see if it can help improve outcomes for me.
[Dr. Jose Silva]:
Yes. You're the only one doing it, so it's not like you can go to the room next door and ask them.
[Dr. Spencer Hiller]:
Yes, I mean, of course, this is all in the interest of trying to improve outcomes, not worsen them. I don't know about you, but I remember during my training that some of my favorite attendings were constantly watching videos of other people operating and I didn't understand it at the time. I totally get it now where when I get into bed at night, I will typically put in my headphones and watch somebody else operate for 30 minutes before I fall asleep. I don't know if that's weird or not, but I'm sure there's others out there that do that.
[Dr. Jose Silva]:
And Spencer, I forgot to ask you in terms of the pre-op, any mandatory or optional testing that you're doing for these patients?
[Dr. Spencer Hiller]:
Yes, I really like to have an accurate size estimation, be it an ultrasound, MRI, a CT of the pelvis, and then they need to have had a cystoscopy at some point. Because most of these patients are referrals from others, most of them have had a cystoscopy already, and I don't repeat it unless something seems a miss to me. They've got a small prostate, but they've got terrible symptoms.
So long as things are adding up, I don't require a repeat cystoscopy, but I do really, really like to have some type of a size estimation. I've had a couple circumstances where insurance wouldn't approve ultrasound, wouldn't approve a CT pelvis, wouldn't approve an MRI, and I've just had to go ahead based on a cystoscopy, but for the most part, they have that.
[Dr. Jose Silva]:
Yes, for Aquablation, for example, I'm having a specific insurance that they need to have an ultrasound of the prostate. If they have the MRI, that's not the equivalent.
HoLEP Procedure Steps
Accurate prostate size estimation is crucial for the success of HoLEP procedures. This information can be obtained through imaging modalities such as ultrasound, MRI, or CT of the pelvis. Additionally, pre-operative cystoscopy is recommended to assess the prostate size and anatomy further.
In the operating room, the procedure typically begins with releasing the apex of the prostate. This involves making an incision at the bladder neck that extends to the apex, guided by the prostate's size and anatomy. This approach, often referred to as the two- or three-lobe technique, allows for precise visualization of the enucleation process in the distal prostate and facilitates controlled tissue removal. Precision is prioritized over speed to minimize trauma, emphasizing the importance of flexibility in technique and tool selection, as each prostate presents unique challenges.
The next step focuses on the median lobe. A five and seven o’clock incision is made at the bladder neck, extending distally to just proximal to the ejaculatory duct. This follows the principles of the three-lobe technique and sets the stage for addressing the lateral lobes. For the lateral lobes, an incision is made lateral to the verumontanum. A scope is then passed over the verumontanum to create a clear plane for tissue removal.
Once all the prostate lobes have been addressed, the nephroscope is introduced. This allows the morcellator probe to be used effectively for removing enucleated tissue.
[Dr. Spencer Hiller]:
Does that have to be a transrectal ultrasound? That's a tough sell for a lot of guys.
[Dr. Jose Silva]:
I took to that, supposedly, we can do it in the OR at the same time and then put it in the note, but it's a little bit more time in terms of the workup or trying to get these patients into the OR. Spencer, so going back to the technique, your technique, has it changed since you started seeing them back in the fellowship?
[Dr. Spencer Hiller]:
Yes, there's a lot that's the same, there's a lot that's different. The very first thing I do is release the apex of the prostate, which is not something that I was doing during the training. If the prostate's not too big, I will start doing it en bloc. Meaning, rather than the traditional three lobe or two lobe technique where you start with an incision at the bladder neck and carry it all the way out to the apex of the prostate.
If I have a good view and I feel like I have a good sense of where I am in the prostate, I can carry on that apical incision proximally and not have to, after incising the apex, return to the bladder neck and just do this standard two lobe or three lobe technique. Especially for anybody training, it's really important to have your default safety procedure or backup.
I still have times where I'm struggling to find the bladder neck anteriorly or struggling to get over top of the prostate and I have to resort to the traditional way that I was trained. This goes back to the flexibility thing. I think it's just important to be flexible and be constantly adapting. Everything that I do or any changes have been in the interest of trying to cut down on that incontinence risk, to be honest.
[Dr. Jose Silva]:
It's not about time, it's about result.
[Dr. Spencer Hiller]:
Yes, if you want me to be honest, I really try to minimize the trauma distally as much as I can.
[Dr. Jose Silva]:
Describe how you train. You start like you said, GreenLight doing channels as nine and three?
[Dr. Spencer Hiller]:
If guys have a big median lobe, the median lobe is perfect for learning how to do it in a nucleation. You'll start with a incision at five and seven and you carry it down to the bladder neck and then carry that distally basically to just proximal to the verumontanum or the ejaculatory duct and get underneath it. I remember the comparison was like, imagine a seal balancing a ball on the tip of its nose. It's just a image most people can understand. That's really how you carry your incisions more proximally and then flip the lobe into the bladder.
[Dr. Jose Silva]:
You start at five and seven, go down to the Vero, and then you start undermining that tissue and bring it up.
[Dr. Spencer Hiller]:
Yes.
[Dr. Jose Silva]:
Okay.
[Dr. Spencer Hiller]:
That's how you would do the traditional three lobe technique. If that's if you're doing that median lobe separately and then going to move on to the lateral lobes. Most of the time, if I'm not trying to do an en bloc, I will make an incision either at five or seven and carry that all the way to the apex of the prostate, to that initial incision I made just proximal to the sphincter, and then carry that all the way around.
[Dr. Jose Silva]:
Then you go high on the lateral, so 11 and 1.
[Dr. Spencer Hiller]:
When you get to the lateral lobes, you've made like an incision in that fold of the lateral lobe, just lateral to the verumontanum. I wish it was prettier than this, but it truly, you park your scope, just right over the verumontanum and then you shove your hands in one direction. It always finds that perfect plane. It's a perfect way to find out where you need to go.
[Dr. Jose Silva]:
In terms of the sphincter, why do you think going apex first versus the traditional, how you were train?
[Dr. Spencer Hiller]:
If you're not making that initial incision, the most distal part of your enucleation is done bluntly with the scope behind where you can see. You're carrying it around, but you can't see where the back of your scope is actually tearing that tissue. You'll finish it and look.
[Dr. Jose Silva]:
It will be like, if you're doing an open simple with your finger, not seeing where you're actually pulling it out.
[Dr. Spencer Hiller]:
Right. Doing an open simple and rather than that pinching that you do at the apex, it'd be like just pulling it and it tears where it tears. Interesting. You get to decide where that apex of tissue remains.
[Dr. Jose Silva]:
Once you have the lobes in the bladder, you remove the scope and then go in with the nephroscope.
[Dr. Spencer Hiller]:
Yes, the sheath stays in, but everything else comes out.
[Dr. Jose Silva]:
The 26 sheath of the-- Okay. It's the inner part.
[Dr. Spencer Hiller]:
Yes.
[Dr. Jose Silva]:
Okay. Okay.
[Dr. Spencer Hiller]:
Yes. Then there's an adapter for the nephroscope to that 26 sheath.
[Dr. Jose Silva]:
Why is that? Why do you need the nephroscope? The channel's open, is bigger?
[Dr. Spencer Hiller]:
Right. You need a straight wide channel because the morcellator probe is a metal rod.
[Dr. Jose Silva]:
Just like the PCNL.
[Dr. Spencer Hiller]:
Yes. Yes. It's very similar in size and shape, to say that, the shock pulse of the trilogy probe.
Podcast Contributors
Dr. Spencer Hiller
Dr. Spencer Hiller is a urologist and clinical lecturer with University of Michigan Medicine.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2024, June 25). Ep. 174 – HoLEP: Advanced Techniques & Patient Outcomes [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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