How Much Does HoLEP Surgery Cost? Factors That Affect the Price

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

It is a fair and necessary question. You have every right to know how much your surgery will cost before making a decision. And you have every right to understand what you are paying for and why prices vary so much from one centre to another.

I will be as transparent as possible about the factors that influence the cost of HoLEP surgery, what a serious quote should include, and why the lowest price is not always the most economical option in the long run.

Why does the price of HoLEP vary so much?

If you have been requesting quotes, you have probably encountered very significant differences between centres. This is because the cost of a HoLEP depends on multiple factors, and not every centre includes the same items in their quote.

Prostate size

A 40-gram prostate is not the same operation as a 180-gram one. With large prostates, surgical time is longer, more operating theatre time is needed, more anaesthesia time, and occasionally an extra night in hospital. Prostate size is the single factor that most influences the duration of the procedure and, therefore, the associated costs.

Type of anaesthesia

HoLEP can be performed under general anaesthesia or spinal anaesthesia. Spinal anaesthesia, when feasible, is safer in older patients, allows faster recovery, and slightly reduces costs. In our practice, most patients are operated under spinal anaesthesia.

Length of hospital stay

At ICUA, most patients stay one night in hospital and go home the day after surgery with their urinary catheter, which is removed at a follow-up visit a few days later. Some centres keep patients in hospital until catheter removal — this increases hospital costs without proven clinical benefit.

Surgeon experience

Let me be direct about this. The fees of a surgeon who has performed 10,000 procedures are not the same as those of one who has performed 50. And they should not be. Surgeon experience is the single factor that most influences HoLEP outcomes — complication rates, speed of recovery, likelihood of requiring retreatment, and continence preservation.

When comparing quotes, do not compare numbers alone. Compare what those numbers represent.

Equipment and technology

The holmium laser is a sophisticated piece of equipment that requires constant maintenance and disposable laser fibres of significant cost. A morcellator is also needed to fragment the tissue, along with an operating theatre equipped with a high-definition endoscopic tower. Centres with their own up-to-date equipment can offer greater efficiency than those that hire equipment on a per-procedure basis.

What should a HoLEP quote include?

A complete, honest quote must include all components with no hidden extras. At ICUA, we provide a fixed, itemised quote that includes:

• Surgical team fees: surgeon, assistant, anaesthetist.
• Operating theatre time: full surgical duration.
• Disposable materials: laser fibre, morcellator, catheter, irrigation supplies.
• Hospital stay: private room, medication, nursing care.
• Histopathological analysis: examination of the removed tissue — essential to rule out incidental prostate cancer.
• Postoperative follow-up: follow-up appointments, catheter removal, control flowmetry.

A word of caution when comparing quotes: Some centres offer an attractive initial price that does not include the anaesthesia, histopathological analysis, or follow-up visits. Always request a full breakdown before making comparisons. A quote that does not include pathology analysis of the removed tissue is, in my view, unacceptable — choosing not to analyse the tissue means choosing not to diagnose a possible incidental cancer.

Insurance and HoLEP

Private insurance in Spain

Most private insurers in Spain cover surgery for benign prostatic hyperplasia, including HoLEP, when there is a medical indication. However, conditions vary between companies and between policies. Some points to consider:

• Some insurers require prior authorisation and may insist that medical treatment has been tried before approving surgery.
• Reimbursement may be partial if the surgeon or facility is not within the insurer's approved network.
• Co-payment policies may cover a variable percentage of the total cost.

At ICUA, we treat patients from all major Spanish insurers and manage the necessary authorisations. We recommend checking with your insurer before your first visit to understand the specific conditions of your policy.

International patients

We receive patients from all over the world — Europe, the Middle East, Latin America, Asia. For international patients, we provide a detailed medical invoice and a comprehensive clinical report that facilitates reimbursement from your insurer or healthcare system in your home country. The cost of HoLEP in Spain is significantly lower than in countries such as the United States, the United Kingdom, or Switzerland, with outcomes comparable to or better than the leading international centres.

The hidden cost: the surgery that needs repeating

This is the most important consideration in this article, and one that rarely appears when prices are being compared.

Transurethral resection (TURP) — the classic technique — has a retreatment rate of 10–15% at 8–10 years. This means that roughly one in seven or eight patients will need to be operated on again. That second operation is more complex, carries more risk, and naturally comes with an additional cost.

HoLEP, by removing the entire adenoma, has a retreatment rate below 2%. In our series of 754 patients with long-term follow-up, the likelihood of requiring reoperation due to regrowth is exceptional.

If a HoLEP costs somewhat more than a TURP but virtually eliminates the possibility of a second operation, which is truly the more expensive option? And that is without factoring in the cost to quality of life — going through surgery again, another period off work, another recovery.

The right question is not "how much does it cost to have surgery?" but "how much will it cost to solve this problem once and for all?" And the answer to that second question almost always favours HoLEP.

Why Spain? A note for patients travelling for surgery

Spain has become one of the leading destinations in Europe for prostate surgery, and for good reason. The combination of highly experienced surgeons, modern private hospital infrastructure, competitive pricing, and a pleasant climate for recovery makes it an attractive option for patients from countries where either the wait is too long, the cost is prohibitive, or the expertise in HoLEP is limited.

At ICUA, we have developed a streamlined pathway for international patients: remote consultation with review of imaging and blood tests, a fixed all-inclusive quote before you travel, surgery within days of arrival, and a detailed discharge report in your language for continuity of care back home, although we remain available for continued online follow-up.

How to request a personalised quote

Every case is different. Prostate size, the patient's medical conditions, and their insurance situation mean it is not possible to provide a single price for everyone.

What we can do is give you a fixed, detailed quote with no hidden extras after the first consultation, once we have the ultrasound and know your case. If you are coming from outside Madrid or from abroad, we can carry out an initial assessment by video consultation using the tests you already have, and provide an indicative quote before you travel.

Want to know how much your surgery would cost?

Request a consultation or video consultation. We will provide a fixed, personalised quote with no obligation.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

1. Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
2. Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
3. Rücker F, Lehrich P, Gilfrich C, et al. HoLEP in three different techniques: a comparison of 600 patients. World J Urol. 2021;39:4063-4069. DOI
4. Tricard T, Xia M, Trambert C, et al. Open prostatectomy is dead — long live endoscopic enucleation of the prostate! World J Urol. 2023;41:1457-1463. DOI

Related articles

→ HoLEP vs TURP, GreenLight, Aquablation & Open Surgery: An Evidence-Based Comparison → HoLEP Prostate Surgery: What to Expect Before, During and After → Finding the Best HoLEP Surgeon: What to Look for and Why Experience Matters → International Patients: Having HoLEP Prostate Surgery in Madrid

Does HoLEP Affect Erections and Sexual Function? What the Evidence Shows

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

It is the question that concerns men most when considering prostate surgery. More than pain, more than anaesthesia, more than the hospital stay. "Doctor, will I still be able to have sex?" And the second question, often asked with more hesitation: "Will I still ejaculate?"

I will answer with complete honesty, because I believe a patient about to make a decision about his body deserves clear information — neither sugarcoated nor dramatised.

First and foremost: HoLEP does not affect erections

This needs to be said clearly from the start. Erections depend on two nerves — the cavernous or erectile nerves — that run along the back and sides of the prostate, outside the capsule. Prostatic enucleation works inside the capsule, peeling the adenoma away without touching these nerves at any point.

If a patient had normal erections before surgery, he will continue to have them afterwards. In fact, some patients report an improvement in their sex life after the operation, simply because the urinary symptoms that were limiting it — getting up four times a night, urgency, constant dribbling — have disappeared. When those problems go away, confidence and comfort improve, and with them, intimacy.

If a patient already had erectile dysfunction before surgery (which is common at this age and with conditions such as diabetes or hypertension), the operation will not make it worse, but it will not cure it either — they are separate problems.

Retrograde ejaculation: what it is and why it happens

This is where I need to be completely transparent. After a complete prostatic enucleation — whether HoLEP, TURP, open surgery, or any other technique that removes the adenoma — most patients experience what we call retrograde ejaculation.

What does that actually mean?

During orgasm, the semen instead of coming out through the penis flows backwards, into the bladder. The orgasm is felt, the sensation of pleasure is there, but there is no expulsion of semen. When the patient urinates after orgasm, the urine comes out slightly cloudy — that is the semen mixed with urine. It is completely harmless.

Why does it happen?

The ejaculatory mechanism depends on a closure that occurs at the prostatic urethra during orgasm. This closure prevents semen from going towards the bladder and directs it outward. When the prostatic adenoma is removed, this closure mechanism is disrupted. This is an inherent consequence of all techniques that completely remove the adenoma — it is not specific to HoLEP.

How common is it?

In the published literature, the rate of retrograde ejaculation after HoLEP ranges from 70 to 90%. It is similar with TURP (75–80%) and with open surgery. In other words: it is the norm, not the exception.

Is it dangerous?

No. Retrograde ejaculation has no health consequences whatsoever. The semen is eliminated naturally with urine. It is painless, does not cause infections, and creates no problems.

Does it affect fertility?

Yes. If a man wishes to father children and preserving antegrade ejaculation is a priority, this must be discussed before surgery. Options exist for sperm banking before the procedure, and assisted reproduction techniques can use semen recovered from urine after orgasm. But if future fertility is important, it is a factor that may tip the balance toward a more conservative treatment.

What patients actually tell me

After thousands of enucleations and asking my patients directly about their experience, I can share what they convey:

When I ask whether they miss ejaculation, they often say yes. It is a different sensation — something is missing.

When I ask about orgasm, the answers vary. Some tell me it is more intense and satisfying than before. Others notice no significant difference. And others tell me, with some regret, that it has become a mild "tingle" — not as good as before.

But when I ask whether they would have the same operation again, the answer is almost unanimous: yes. They tell me that their life, overall, has improved enormously despite the retrograde ejaculation, and that they would do it again without hesitation.

An objective data point: In a prospective satisfaction study (Lee, 2017) of 397 patients at six months after HoLEP, only 3.3% were dissatisfied and 3.9% would not have had surgery if they could choose again. Notably, the reasons for dissatisfaction were not ejaculation — they were persistent urgency and nocturia not improving as much as expected.

Can ejaculation be preserved with prostate surgery?

Yes, but with important caveats that the patient must understand before deciding.

Minimally invasive treatments (Rezum, UroLift, iTIND)

These procedures have been commercially positioned as ejaculation-preserving options. And it is true that they preserve ejaculation in most cases. However, the improvement in urinary flow is significantly less than with enucleation, durability is limited, and many patients will eventually require retreatment.

Laser-based options that preserve ejaculation

In our practice, we have two minimally invasive laser-based options for carefully selected patients who prioritise ejaculatory preservation:

The first is bilateral bladder neck incision with laser, in younger patients with an elevated, narrow bladder neck. If the incisions are kept half a centimetre to one centimetre above the verumontanum, ejaculation is preserved consistently. In my personal experience, I have had only one case of antegrade ejaculation loss with this technique, and we perform it virtually every week. It is done under sedation, takes 3–4 minutes, and the patient goes home the same day with a catheter for removal the following day.

The second is isolated middle lobe enucleation in patients whose obstruction is mainly caused by middle lobe growth. If the tissue around the verumontanum is preserved, ejaculation is consistently maintained and there is a very significant improvement in urinary symptoms.

These two options strike me as quite competitive compared to other minimally invasive treatments, but not every patient is a candidate. Selection is crucial, and we perform a prior cystoscopy to confirm that the patient's anatomy is suitable.

Ejaculation-sparing HoLEP

Attempts have been published to perform complete enucleation while preserving tissue around the verumontanum to maintain ejaculation. Results to date are modest — success rates of around 50%. And there remains uncertainty about whether leaving adenomatous tissue behind compromises the procedure's durability, with the risk that this residual tissue may grow and cause obstruction again.

Putting things in perspective

When I advise my patients on this topic, I often share something I believe is important: most of the men we operate on are 55–65 years old or older. Over time, the importance of antegrade ejaculation tends to diminish, but being able to urinate properly will become increasingly important. I have seen too many patients who at 75–80 are admitted for a hip fracture and develop urinary retention because a conservative approach was chosen decades earlier.

The medical device industry has invested enormous sums in shifting our perception of the relative importance of ejaculation versus bladder function. And they have been extraordinarily effective in that marketing effort. But as urologists, we should be advisors to our patients, not sales representatives for any company.

The decision always belongs to the patient. But for it to be a truly informed decision, he needs to know all the facts — not just the ones the advertising highlights.

In summary:

• Erections: not affected. The erectile nerves are not touched during surgery.
• Ejaculation: in 70–90% of cases it will be retrograde (dry). Orgasm persists.
• Overall satisfaction: over 96% of patients are satisfied and would have the surgery again.
• Ejaculation-preserving options exist for selected patients, but with lower efficacy or durability.

Have questions about how HoLEP might affect your sex life?

At ICUA we will explain all the options honestly and personally.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

1. Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
2. Kim M, Song SH, Ku JH, et al. Pilot study of the clinical efficacy of ejaculatory hood sparing technique for ejaculation preservation in HoLEP. Int J Impot Res. 2015;27:20-24. PubMed
3. Lee SW, Choi JB, Lee KS, et al. Satisfaction and quality of life after holmium laser enucleation of the prostate. Investig Clin Urol. 2017;58:35-41. DOI
4. Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release. World J Urol. 2019;37:2451-2458. PubMed
5. Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed

Related articles

→ What Is HoLEP? A Complete Guide to Holmium Laser Enucleation of the Prostate → HoLEP Prostate Surgery: What to Expect Before, During and After → HoLEP vs TURP, GreenLight, Aquablation & Open Surgery: An Evidence-Based Comparison → Tamsulosin, Dutasteride and BPH Medications: When to Stop Pills and Consider Surgery

Benign Prostatic Hyperplasia (BPH): Symptoms, Diagnosis and Treatment Options in 2026

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

If you find yourself getting up several times at night to urinate, if your stream is not what it used to be, if you have the feeling that your bladder never fully empties — you are not alone. These symptoms are extraordinarily common in men over 50, and in most cases they have a benign, treatable cause: benign prostatic hyperplasia.

In this article, I explain exactly what this condition is, how it is diagnosed, what treatment options are available in 2026, and when it is time to consider surgery.

What is benign prostatic hyperplasia?

The prostate is a walnut-sized gland that surrounds the urethra — the tube through which urine exits the bladder. From the age of 30, prostatic tissue begins to grow slowly but progressively. This growth is benign (it is not cancer) and is called benign prostatic hyperplasia, or BPH.

Over time, this growth can compress the urethra and make it difficult for urine to flow. BPH affects 50% of men by the age of 60 and up to 80% by 70. Not all will experience symptoms, but many do — and for some, the symptoms are bothersome enough to seriously impact quality of life.

It is important to understand that BPH is not prostate cancer and does not evolve into it. They are two different conditions that can coexist, but one does not cause the other.

The symptoms: how to know if you have a prostate problem

BPH symptoms fall into two broad categories:

Obstructive symptoms (voiding)

These occur when the urethra is compressed and urine struggles to flow out:

• Weak stream: you notice the force of your stream has diminished over time.
• Hesitancy: you have to wait or strain before the flow begins.
• Intermittent stream: the flow stops and starts.
• Incomplete emptying: you finish urinating but feel there is urine left in the bladder.
• Terminal dribbling: drops continue to fall after you think you have finished.

Irritative symptoms (storage)

These are caused by the bladder becoming overactive — when it detects obstruction, it contracts involuntarily hundreds of times a day trying to overcome the resistance:

• Urgency: a sudden, compelling need to urinate that is difficult to control.
• Frequency: urinating far more often than normal during the day.
• Nocturia: getting up to urinate during the night — once, twice, three times or more.
• Urge incontinence: not reaching the toilet in time and leaking urine.

Warning signs that require urgent attention:

• Complete inability to urinate (acute urinary retention) — go to A&E immediately.
• Blood in the urine (haematuria).
• Fever with difficulty urinating — may indicate infection.
• Lower back pain with urinary difficulty — may indicate kidney involvement.

When to see a urologist

If your symptoms are bothersome, limit your daily activities, affect your sleep, or restrict your ability to travel, a urological assessment is worthwhile. There is no need to wait until things become serious. In fact, it is preferable not to wait too long: BPH is progressive, and a bladder that has spent years fighting against obstruction can undergo functional deterioration that is sometimes not fully reversible.

In our clinic, the assessment is quick. Within 10 minutes — using an ultrasound, a flowmetry test, and a blood test with PSA — we have the information needed to advise the patient on the best course of action for their case.

Diagnosis: what tests will be done

Diagnosing BPH is straightforward and non-invasive:

• Clinical history and IPSS questionnaire: a standardised form that quantifies symptom severity on a scale of 0 to 35.
• Digital rectal examination (DRE): allows estimation of prostate size and consistency. It is a brief, painless examination that is optional. We never force anyone to have a rectal exam if they do not wish to have it.
• Blood test with PSA: prostate-specific antigen helps rule out cancer and gives an indication of prostate size.
• Ultrasound: visualises the prostate, bladder, and kidneys. Allows measurement of prostate size and checks whether urine remains in the bladder after voiding (post-void residual).
• Flowmetry: the patient urinates into a device that measures flow speed. A peak flow below 15 ml/s suggests obstruction.

In some cases, if the flowmetry pattern suggests a urethral stricture, we perform a flexible cystoscopy in the same consultation to rule it out. And if nocturia is the predominant symptom, we request a voiding diary to determine whether it is nocturnal polyuria — a different problem that will not improve with prostate surgery.

Treatment options

1. Lifestyle changes

In mild cases, adjusting certain habits can make a significant difference: reducing fluid intake in the evening, limiting coffee, tea, and alcohol (especially beer), avoiding constipation, and exercising regularly. These changes do not cure BPH, but they can relieve symptoms enough to live comfortably without treatment.

2. Medical therapy

When lifestyle changes are not enough, several types of medication are available:

• Alpha-blockers (tamsulosin, silodosin, alfuzosin): relax the smooth muscle of the prostate and bladder neck, making it easier for urine to flow. They act quickly (within days) but can cause dizziness, nasal congestion, and ejaculatory problems.
• 5-alpha-reductase inhibitors (finasteride, dutasteride): shrink the prostate by blocking the conversion of testosterone to dihydrotestosterone. They take months to take effect and can affect libido and erectile function.
• Combination therapy: alpha-blocker + 5-alpha-reductase inhibitor. More effective than either drug alone, but also with more side effects.
• Antimuscarinics or beta-3 agonists: to treat the associated overactive bladder.

Medical therapy is effective for many patients, but it has its limits. It does not cure BPH — it manages it. If the medication is stopped, the symptoms return. And some patients experience side effects that reduce their quality of life as much as, or more than, the prostatic symptoms themselves.

3. Minimally invasive treatments

Several procedures sit between medication and surgery: Rezum (steam therapy), UroLift (retractor implants), and iTIND (a temporary reshaping device). They are performed on an outpatient basis or with very short hospital stays, and their main appeal is ejaculatory preservation.

However, the improvement in urinary flow is more modest than with surgery, durability is limited, and the probability of requiring retreatment is significantly higher. I believe they are a good option for carefully selected patients who prioritise ejaculatory preservation over maximum efficacy, but they do not replace definitive surgical options.

4. Definitive surgery

When medication is insufficient, when complications have developed, or when the patient simply wants to resolve the problem once and for all, surgery is the answer. The main options are:

• TURP (transurethral resection): the classic technique. Effective for medium-sized prostates but limited for large ones, with a retreatment rate of 10–15%.
• GreenLight laser vaporisation: good for medium prostates, very safe regarding bleeding, but no tissue specimen and slow for large glands.
• HoLEP (holmium laser enucleation): removes the entire adenoma regardless of size, with a retreatment rate below 2%. Recommended by EAU and AUA guidelines for any prostate size.
• Open surgery: effective but invasive, with long hospital stay and prolonged recovery. Increasingly being replaced by HoLEP.

What if I do not have surgery? The risks of untreated BPH

Untreated BPH can lead to complications that go beyond mere urinary discomfort:

• Acute urinary retention: complete inability to urinate, requiring emergency catheterisation.
• Bladder damage: a bladder that has spent years working against obstruction loses its contractile ability. This damage may be irreversible.
• Recurrent urinary infections: residual urine left in the bladder is a breeding ground for bacteria.
• Bladder stones: form in stagnant urine.
• Bladder diverticula: the bladder wall herniates, forming pouches.
• Kidney damage: in advanced cases, obstruction can affect the kidneys (hydronephrosis).

A recent study involving 50,000 subjects demonstrated that the bladder muscle deteriorates progressively as obstruction advances, and that there is a window of opportunity to treat the patient before that deterioration becomes permanent. I do not say this to cause alarm, but to help you understand that postponing urological assessment indefinitely is not a wise strategy.

As I often tell my patients: "You don't have to be the first to have surgery, but you shouldn't be the last either."

Do you have urinary symptoms that concern you?

At ICUA we provide a complete assessment in a single visit. If treatment is needed, we will explain all the options.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

1. Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to BPH: AUA guideline amendment 2023. J Urol. 2024;211:11-19. DOI
2. EAU Guidelines on Management of Non-neurogenic Male LUTS. 2025 Edition. EAU Guidelines
3. Egan KB. The epidemiology of benign prostatic hyperplasia associated with lower urinary tract symptoms. Urol Clin North Am. 2016;43:289-297. DOI
4. Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
5. Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed

Related articles

→ What Is HoLEP? A Complete Guide to Holmium Laser Enucleation of the Prostate → HoLEP vs TURP, GreenLight, Aquablation & Open Surgery: An Evidence-Based Comparison → HoLEP Prostate Surgery: What to Expect Before, During and After → Tamsulosin, Dutasteride and BPH Medications: When to Stop Pills and Consider Surgery

Very Large Prostate? Why En Bloc HoLEP Is the Best Option for Prostates Over 100 Grams

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

If you have been told that your prostate is very large — 100, 150, 200 grams or more — and that you need surgery, you have probably been offered two options: open surgery (an abdominal incision) or living with a catheter. There is a third option that you may not have been offered, because not all centres can perform it: en bloc holmium laser enucleation of the prostate (HoLEP).

And it does not just work for large prostates — it is where it works best.

What is considered a large prostate?

Prostate size is usually measured in grams or millilitres (they are essentially equivalent). A useful classification:

• Small: under 30 grams — rarely requires surgery.
• Medium: 30–80 grams — most techniques work well.
• Large: 80–150 grams — this is where many techniques start to struggle.
• Very large: over 150 grams — territory where few techniques are viable.

Size matters because it determines which surgical techniques can be used safely and effectively. And it is precisely with large and very large prostates that the differences between techniques become most apparent.

The problem with large prostates and conventional techniques

TURP (transurethral resection)

TURP has a practical ceiling around 80 grams. Attempting to resect a 150-gram prostate with an electrical loop is like trying to empty a well with a bucket: it takes too long, there is too much bleeding, and you never manage to remove all the tissue. The risk of fluid absorption syndrome (TUR syndrome) increases with operating time. This is why the clinical guidelines do not recommend TURP for large prostates.

GreenLight laser

GreenLight vaporisation works well for medium-sized prostates, but for large ones it faces the same problem: vaporising 100 or 150 grams of tissue takes an excessive amount of time, and it is very difficult to ensure all the adenoma has been removed. The retreatment rate for large prostates treated with GreenLight can reach 9%.

Aquablation

Aquablation is approved for prostates between 30 and 150 ml. It has an upper size limit, and data in large prostates show significantly higher rates of postoperative bleeding. It is not an enucleative technique — it destroys part of the adenoma but does not remove it completely.

Open surgery

Open simple prostatectomy is effective for prostates of any size — the surgeon opens the abdomen and removes the adenoma with their fingers. It works, but at considerable cost to the patient: abdominal incision, significant bleeding, 5–7 day hospital stay, prolonged catheterisation, and 4–6 weeks' recovery. For over a century it was the only option for large prostates. It no longer needs to be.

Why en bloc HoLEP has no size limit

HoLEP follows the natural anatomical plane between the adenoma and the prostatic capsule — the very same plane that the surgeon's finger follows in open surgery. But it does so with laser precision, without incisions, and with minimal bleeding.

And here is the paradox: the larger the prostate, the more efficient en bloc enucleation becomes. Why? Because in large prostates the plane between adenoma and capsule is better defined — easier to find and follow. The adenoma is softer, more pedunculated, and peels away more readily. It is like peeling a large orange: the segments separate from the peel with less effort than in a small one.

Our published data on large prostates

In 2025, we published in World Journal of Urology the results of 754 consecutive patients operated with our en bloc technique. Of these, 110 had prostates of 120 grams or more (median 143.5 grams). We compared them with the 644 patients with smaller prostates.

Parameter	Prostate <120 g (n=644)	Prostate ≥120 g (n=110)
Size (median)	60 g	143.5 g
Enucleation time	25 min	40 min
Enucleation efficiency	1.9 g/min	3.1 g/min
Tissue removed	38.9 g	98.7 g
Stress incontinence 1 month	3.4%	8.2%
Stress incontinence 3 months	1.4%	1.8%
Stress incontinence 6 months	0.15%	0.9%
Transfusion rate	0.31%	0.9%
PSA reduction	92.9%	94.4%
Qmax at 3 months	24 ml/s	28 ml/s

Several findings deserve comment:

Efficiency doubles in large prostates. We enucleated at 3.1 g/min in the large group versus 1.9 g/min in the normal group. This confirms that the dissection plane is better defined in larger glands.

Continence at 6 months is excellent in both groups. At one month, the large prostate group does have slightly more transient incontinence (8.2% vs 3.4%), which is expected — more tissue has been manipulated near the sphincter. But by 3 months the figures are comparable, and by 6 months they are below 1% in both groups.

PSA reduction is 94.4% in large prostates — even higher than in the normal group. This demonstrates the completeness of the enucleation: virtually all the adenoma has been removed.

Postoperative urinary flow is actually higher in the large prostate group (28 ml/s vs 24 ml/s), because the cavity left after removing a large adenoma allows a wider urinary channel.

Beyond 150 grams: prostates of 200, 300, and even 500 grams

In our experience, we have operated on prostates of exceptional size — 300, 400, and even 500 grams — with excellent results. These are cases that historically could only be resolved with open surgery, with everything that entails for the patient.

A multicentre study published in World Journal of Urology in 2023 by Tricard and colleagues, boldly titled "Open simple prostatectomy is dead," demonstrated excellent HoLEP outcomes in prostates over 150 ml, confirming that there is no longer any justification for opening a patient's abdomen to operate on their prostate.

Specific advantages of the en bloc approach for large prostates

• Shorter morcellation time: Removing the adenoma in a single piece means subsequent fragmentation is faster and more efficient than if two or three separate lobes had been pushed into the bladder.
• Complete specimen for histopathology: All the tissue is sent to the pathologist, allowing a thorough histological assessment. This is particularly important in large prostates, where the probability of finding incidental cancer is low but not negligible.
• Better orientation during surgery: Dissecting en bloc means the surgeon always has a clear anatomical reference. In a 200-gram prostate, getting lost inside the adenoma is easy with fragmented techniques — with en bloc, you always know where you are.

"The prostate complicates old age"

This is a concept I always explain to my patients. A man who at 60–65 has a large obstructive prostate and decides not to undergo surgery runs the risk that at 75–80, when admitted for a hip fracture or knee replacement, he will develop urinary retention that dramatically complicates his life. A large prostate does not stop growing, and the bladder deteriorates with every year of untreated obstruction.

The great advantage of enucleation is that it offers a very high probability of being the only treatment the patient will ever need. We are not "fixing a tooth" that will need retreating in a few years. We are solving the problem definitively.

Have you been told your prostate is too large for surgery?

Send us your medical reports for a second opinion. At ICUA, we operate on prostates of any size.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

1. Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
2. Tricard T, Xia S, Xiao D, et al. Outcomes of HoLEP for very large-sized BPH (over 150 mL): open simple prostatectomy is dead. World J Urol. 2023;41:2249-2253. DOI
3. Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release. World J Urol. 2019;37:2451-2458. PubMed
4. Juliebø-Jones P, Gauhar V, Castellani D, et al. En-bloc vs non en-bloc for large and very large prostates: propensity score matched analysis. World J Urol. 2024;42:299. DOI
5. Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
6. Gomez Sancha F, Rivera VC, Georgiev G, et al. Common trend: move to enucleation — Is there a case for GreenLight enucleation? World J Urol. 2015;33:539-547. DOI (Open Access)

Related articles

→ What Is HoLEP? A Complete Guide to Holmium Laser Enucleation of the Prostate → HoLEP vs TURP, GreenLight, Aquablation & Open Surgery: An Evidence-Based Comparison → HoLEP Prostate Surgery: What to Expect Before, During and After → Living with a Catheter Due to BPH: Can HoLEP Help?

Finding a good HoLEP Surgeon: What to Look for and Why Experience Matters

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

HoLEP is arguably the most surgeon-dependent technique in urology. Having a good laser is not enough — you need to know how to use it. The learning curve is real, and the difference between an experienced surgeon and one who is just starting out can mean longer operating times, higher complication rates, and worse functional outcomes.

If you are looking for a surgeon to perform your prostate operation with HoLEP, this article will help you ask the right questions and understand what distinguishes a centre of excellence from one that simply has the equipment.

Why HoLEP depends more on the surgeon than on the machine

Laser enucleation of the prostate is not like programming a robot or pressing a button. It is a manual technique that requires three-dimensional understanding of prostatic anatomy, recognition of the plane between the adenoma and the capsule, sphincter protection, and real-time decision-making when the anatomy is not as expected. Every prostate is different, and the surgeon must adapt.

Published studies indicate that 20 to 50 procedures are needed to achieve basic competence with HoLEP, depending on the technique used and whether an experienced mentor provides supervision. But basic competence is not the same as mastery. A study from the University of Mannheim following 500 consecutive en bloc cases showed that surgeon efficiency continued to improve even after hundreds of procedures — without reaching a plateau.

In practical terms, this means: the more procedures your surgeon has performed, the better your outcome is likely to be.

Five questions you should ask your surgeon before deciding

1. How many enucleations have you performed?

This is the most important question. A surgeon who has done 50 enucleations does not have the same capability as one who has done 500, and that surgeon is not comparable to one who has done 5,000 or 10,000. Cumulative surgical volume is the best predictor of outcomes.

Do not just ask how many HoLEP procedures they do per year — ask how many they have done in total. A surgeon doing 100 per year for two years has a very different experience level from one who has been performing this technique for 20 years.

2. Have you published your own results?

Any surgeon can claim their outcomes are good. But publishing results in a peer-reviewed scientific journal means the data have been verified and validated by independent experts. Ask whether they have PubMed-indexed publications with their own HoLEP data — complication rates, continence outcomes, retreatment rates.

3. Do you train other surgeons?

A surgeon to whom other urologists come to learn has, by definition, a level of mastery that goes beyond competence. Teaching forces systematisation, an understanding of nuances, and the ability to solve problems that a less experienced surgeon has never encountered. Ask whether they receive visitors to their operating theatre, whether they run training courses, whether they proctor (supervise) at other hospitals.

4. Which technique do you use?

Not all HoLEP variants are equal. The en bloc enucleation technique with early apical release has been shown to be faster, more efficient, and to provide better continence protection than the classic three-lobe technique. Ask your surgeon which technique they use and why.

5. Can you operate on prostates of any size?

A HoLEP centre of excellence should be able to handle prostates of any volume — from small to very large, 200, 300 grams or more. If you are told your prostate is "too big for HoLEP," you are probably not at a centre with the necessary experience. One of HoLEP's greatest advantages is precisely that it has no size limit.

ICUA and Dr. Gómez Sancha: objective data

I do not intend this article to be a self-promotional exercise. What I will share are verifiable data — published in peer-reviewed international scientific journals, accessible on PubMed for anyone who wishes to check them.

Surgical experience

• Over 10,000 prostatic enucleations performed since 2003.
• Laser prostatectomy since 2003 — first with GreenLight, then with holmium laser (HoLEP).
• We operate on prostates of any size, including the very largest (300–500 grams).

Published technique

• GreenLight en bloc enucleation (GreenLEP): described and published in World Journal of Urology in 2015. The first description of en bloc enucleation with this energy source.
• En bloc HoLEP with early apical release and sphincteric mucosal preservation: published in World Journal of Urology in 2019 (137-patient series). Mean operative time 47 minutes, stress incontinence 0.7% at 6 months.
• 754-patient consecutive series: published in World Journal of Urology in 2025. Stress incontinence at 6 months: 0.15% for normal-sized prostates, 0.9% for large prostates. Postoperative PSA reduced by 93–94%.

International registries

• REAP Registry: co-author of the largest global multicentre database for prostatic enucleation — 6,193 patients from 10 centres in 7 countries, published in World Journal of Urology in 2023.
• Multicentre early apical release study: co-author of a 4,392-patient study evaluating the impact of early apical release, published in Urology in 2024.

International training

• Over 60 countries represented in our operating theatres in Madrid (ICUA, Clínica CEMTRO) and Sofia (Hill Clinic, Bulgaria).
• Active training programme since 2007: weekly surgical sessions with 5 procedures per session, open to international visitors.
• Training courses in Spain, Bulgaria, Mexico, Philippines, and other countries.
• Invited regularly to perform live surgery in the European annual congress and other minor events
• Published textbook: Manual de HoLEP en Bloque (ISBN 978-84-09-81888-4, 2026) — a 352-page practical manual with the step-by-step technique.

All of these data are verifiable. The publications are on PubMed, the visitors are real, the book has an ISBN. This is not marketing — these are facts.

What makes a centre of excellence?

A HoLEP centre of excellence is not simply a hospital that owns a holmium laser. It is a centre where several factors converge:

• Volume: enough procedures per year to maintain and improve the team's skill.
• Accumulated experience: the surgeon has long surpassed the learning curve and has operated on prostates of every description.
• Published data: the centre has verifiable, published results — not just internal statistics.
• Teaching capacity: other surgeons come to the centre to learn, demonstrating peer recognition.
• Complete team: it is not just the surgeon — it is an anaesthesia, nursing, and follow-up team that knows the protocol inside out.

A personal note: Do not choose your surgeon based on the lowest price or the first Google search result. HoLEP, done well, solves the problem permanently. Done poorly, it can leave you with complications requiring further procedures. The difference between these two scenarios is, almost always, the experience of the person holding the endoscope.

Would you like us to evaluate your case?

At ICUA we treat patients from across Spain and around the world. Send us your medical reports for a personalised assessment.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

1. Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol. 2019;37:2451-2458. PubMed
2. Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
3. Gomez Sancha F, Rivera VC, Georgiev G, et al. Common trend: move to enucleation — Is there a case for GreenLight enucleation? World J Urol. 2015;33:539-547. DOI (Open Access)
4. Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
5. Gauhar V, Lim EJ, Fong KY, et al. Influence of early apical release on outcomes in endoscopic enucleation of the prostate: 4392 patients. Urology. 2024;187:154-161. DOI
6. Wenk MJ, Hartung FO, Egen L, et al. The long-term learning curve of HoLEP in the en-bloc technique: 500 consecutive cases. World J Urol. 2024;42:436. PubMed
7. Li P, Wang C, Tang M, et al. The en bloc method is feasible for beginners learning to perform HoLEP. Transl Androl Urol. 2023;12(3):379-390. PubMed Central

Related articles

→ What Is HoLEP? A Complete Guide to Holmium Laser Enucleation of the Prostate → HoLEP Prostate Surgery: What to Expect Before, During and After → International Patients: Prostate Surgery in Madrid with Dr. Gómez Sancha → How Much Does HoLEP Surgery Cost?

HoLEP Prostate Surgery: What to Expect Before, During and After

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

If you have been recommended prostate surgery with HoLEP, or are considering it, it is natural to want to know exactly what will happen. This article describes the patient experience step by step — before, during, and after the procedure — as we carry it out daily in our operating theatre, after more than 10,000 enucleations.

Before surgery

The consultation: initial assessment

When a patient comes in for consultation, we ask them to bring a blood test with PSA and a urine analysis, and to arrive with a comfortably full bladder (we recommend not urinating for two hours beforehand and drinking 3–4 glasses of water an hour before). In the waiting room, we provide the IPSS questionnaire to assess symptom severity.

In the consultation room, we take a clinical history, review the blood work, perform an ultrasound of the urinary tract with a full bladder, and carry out a flowmetry test. We then check for post-void residual urine with ultrasound. With all this information, we can advise the patient on whether they need medical treatment, monitoring, or whether surgery should be considered.

When do we recommend surgery?

There are two situations. The first is when there is a mandatory indication for surgery: urinary retention requiring a catheter, bladder stones, prostatic bleeding, recurrent infections, or kidney damage. In these cases, surgery should not be delayed.

The second is when the patient meets surgical criteria without a mandatory indication: symptoms affect quality of life and medical treatment is insufficient. In these cases, I always tell the patient that it is important they are genuinely convinced that the operation is necessary, or at least advisable. Operating on a man who is not convinced is a bad idea — if something does not go perfectly, the burden of blame falls on whoever made the recommendation. When the patient actively participates in the decision, they navigate the postoperative period much better.

Medications you need to stop

If you take anticoagulants or antiplatelet agents, it is essential to communicate this. Depending on the type of medication:

• Aspirin, clopidogrel (Plavix), ticlopidine: stop 7 days before surgery.
• Warfarin/acenocoumarol: stop 3 days before and start low-molecular-weight heparin as directed by your surgeon.
• Direct oral anticoagulants (rivaroxaban, apixaban, dabigatran): stop according to the specific protocol for each drug.

It is very important to coordinate this with your urologist and, if necessary, your cardiologist. The holmium laser has excellent haemostatic properties — in our series, the transfusion rate is below 1% — but proper preparation is essential.

The day of surgery

The patient is admitted in the morning, fasting (no food, drink, or smoking for 6 hours beforehand). Surgery is usually scheduled for the afternoon. Before the procedure, the anaesthetist will visit to explain the type of anaesthesia and answer any questions.

During the procedure

Anaesthesia

We generally use spinal anaesthesia (intradural), which numbs the body from the waist down. The patient is awake but feels absolutely nothing in the surgical area. A mild sedative is given so you feel relaxed, and you will likely doze off lightly during the procedure. In some cases, general anaesthesia is used — your anaesthetist will explain the advantages of each option.

How long does the operation take?

It depends on prostate size. In our series of 754 patients:

• Normal-sized prostates (<120 g): 25 minutes of enucleation + 5 minutes of morcellation + haemostasis = approximately 45–60 minutes total.
• Large prostates (≥120 g): 40 minutes of enucleation + 13 minutes of morcellation + haemostasis = approximately 70–90 minutes total.

These times reflect an experience of thousands of procedures. A surgeon at the beginning of their learning curve will require more time, but this does not affect safety or long-term outcomes.

What does the surgeon actually do?

An endoscope is inserted through the urethra to the prostate area. Using the holmium laser, the boundary between the adenoma and the urinary sphincter (the "white line") is marked to protect continence from the very first moment. The adenoma is then gradually peeled off the prostatic capsule circumferentially — like peeling an orange — until the entire piece is pushed into the bladder. There, it is fragmented with an instrument called a morcellator and suctioned out for histopathological analysis.

Finally, haemostasis is checked (ensuring there are no bleeding points) and a urinary catheter is placed.

After surgery

The first few hours

When you leave the operating theatre, you will have a urinary catheter with a slow continuous irrigation to keep the urine clear. After spinal anaesthesia, there is no pain — the only common complaint is being unable to move your legs for a couple of hours until the effect wears off. Most patients do not require painkillers.

The following morning: catheter removal

We follow an early catheter removal protocol that has proven very effective. The nurse flushes the catheter to clear any small clots that formed overnight, removes the catheter, and fills the bladder with saline. The patient gets up and urinates — usually 3–4 times during the morning. If all goes well, discharge is around midday.

With this protocol, approximately 5% of patients have difficulty voiding after removal. In those cases, the catheter is reinserted and the patient goes home with it, returning to the clinic 1–2 days later for removal. If we left the catheter in for 48 hours, 99% would void without trouble — but we prefer early removal so that 95% of patients do not spend an extra day with a catheter unnecessarily.

Discharge medication

We prescribe an anti-inflammatory for one week (usually dexketoprofen 25 mg three times daily) with a gastric protector, and a prophylactic antibiotic for one week. We advise patients to avoid constipation (no straining during bowel movements) and to drink plenty of fluids.

The first few weeks: what is normal

It is important to know what to expect so you do not worry unnecessarily:

• Pinkish urine or mild bleeding for the first few days — this is normal and gradually clears.
• Passing small clots or yellowish particles — these are normal remnants from the healing process.
• Stinging when urinating at the beginning and end of the stream — transient, resolves within days.
• Urgency and frequency — irritative symptoms may persist for up to 3–4 months. Interestingly, the first two to three weeks are often the best, and then urgency and nocturia reappear before improving definitively.

An important note: If you experience stinging or urinary urgency in the weeks following surgery, your GP may perform a urine dipstick test that comes back positive for red and white blood cells. This is completely normal for the first few months — the prostatic fossa is healing. It does not mean you have an infection. Many GPs are unaware of this and may prescribe unnecessary antibiotics.

One-month review

We see the patient after one month. Most already notice a very significant improvement in urinary flow. Some irritative symptoms may persist and will continue to improve.

Three-month review

At three months, the vast majority of patients feel very well. Irritative symptoms are resolved or nearly resolved. We perform a flowmetry, symptom questionnaire, and PSA test. If all is well, we recommend an annual PSA review with their GP.

Results: the numbers that matter

In our published series of 754 patients operated with the en bloc technique:

• Urinary flow: from 8 ml/s preoperatively to 24–28 ml/s postoperatively — an immediate and dramatic improvement.
• IPSS (symptom score): from 24 preoperatively to 3 at 12 months — virtually symptom-free.
• PSA reduction: 93–94% — confirming complete adenoma removal.
• Stress incontinence at 6 months: 0.15% (prostates <120 g) and 0.9% (≥120 g).
• Transfusion rate: below 1%.
• Hospital stay: 24–48 hours in most cases.

An important note for follow-up: PSA

After HoLEP, PSA should drop below 1 ng/mL. If at any future check-up your PSA rises above this level, it needs to be investigated — it may indicate residual adenomatous tissue or, in some cases, prostate cancer requiring further study. It is crucial that your GP knows that the reference value after an enucleation is not the standard "below 4 ng/mL" but below 1 ng/mL.

When can I return to normal life?

• Light domestic activity: from the day after discharge.
• Office work: after 2–3 days.
• Driving: after one week.
• Gentle exercise (walking): from day one. Intense exercise: after 4 weeks.
• Sexual activity: after 3–4 weeks.
• Long-distance travel: after 2–3 weeks, ensuring adequate fluid intake and regular voiding.

Considering HoLEP surgery?

At ICUA we will explain the entire process in a personalised consultation. In-person in Madrid or international video consultation.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

1. Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
2. Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol. 2019;37:2451-2458. PubMed
3. Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
4. Gauhar V, Lim EJ, Fong KY, et al. Influence of early apical release on outcomes in endoscopic enucleation of the prostate: results from a multicenter series of 4392 patients. Urology. 2024;187:154-161. DOI

Related articles

→ What Is HoLEP? A Complete Guide to Holmium Laser Enucleation of the Prostate → HoLEP vs TURP, GreenLight, Aquablation & Open Surgery: An Evidence-Based Comparison → Does HoLEP Affect Erections and Sexual Function? → Very Large Prostate? Why En Bloc HoLEP Is the Best Option