Living with a Catheter Due to BPH: Can HoLEP Help?

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

If you are reading this with a urinary catheter in place, I understand what you are going through. The catheter is uncomfortable, it restricts your mobility, you worry about infections, and every passing day feels like your life is on hold. Perhaps you have been told to wait, that you will be placed on a waiting list, or that your prostate is too large for endoscopic surgery.

I want you to know something important: the catheter can be removed. In the vast majority of cases, HoLEP can resolve the obstruction definitively and restore the patient's ability to urinate normally, even after months or years of catheterisation.

Why is a permanent catheter placed?

A permanent urinary catheter is placed when a patient cannot urinate on his own — what we call urinary retention. This happens when the prostate has grown to a point where it completely blocks the outflow of urine. Sometimes it occurs acutely (from one day to the next, often after a heavy meal, a long journey, or a cold), and sometimes it is the end point of progressive deterioration.

In A&E, the catheter is placed as an emergency measure. The problem is that, afterwards, the patient can remain in limbo: an attempt is made to remove the catheter with medication (alpha-blockers), and if it fails, the catheter is replaced. And so it continues — weeks or months with a catheter, waiting for a surgical solution that sometimes takes far too long to arrive.

What the catheter does to your quality of life

You do not need me to explain this — you live it every day. But it is worth naming the consequences to underscore the urgency of resolving the situation:

• Recurrent urinary infections — every catheter change carries a risk of infection.
• Constant discomfort, urethral irritation, bladder spasms.
• Limitations on travel, exercise, and normal daily activities.
• Psychological impact: loss of independence, embarrassment, social withdrawal.
• Risk of urethral damage from prolonged catheterisation.

Can the catheter be removed permanently?

Yes. In the vast majority of cases, yes.

HoLEP removes all the prostatic tissue causing the obstruction, regardless of its size. By eliminating the cause of the retention, urine can flow freely again. In our experience, patients who were catheterised before surgery are the ones who experience the most dramatic change in quality of life — they go from depending on a catheter to urinating normally, often with a flow rate better than anything they had experienced in years.

It does not matter if your prostate weighs 80, 120, or 200 grams. It does not matter if you have been catheterised for weeks or months. What matters is that the bladder still has the ability to contract — and this is something we can assess before surgery.

The surgical challenge of the catheterised patient

I must be honest: operating on a patient who has been catheterised for a long time is not exactly the same as operating on someone who walks in from the outpatient clinic. There are specific considerations that must be managed carefully.

Infection and sepsis

The catheterised patient almost always has bacteria in the urine — it is virtually inevitable with a foreign body permanently in the urinary tract. If not managed properly, surgical manipulation can cause bacteraemia or, in the worst case, sepsis.

This is a risk I take extremely seriously. At ICUA, we have developed a rigorous preventive protocol: we change the catheter in clinic days before surgery and send the tip to the laboratory for culture. We begin targeted antibiotic therapy based on the sensitivity pattern at least 4 days before the operation. If the organisms are multidrug-resistant and there are no oral options, we admit the patient for intravenous antibiotics beforehand. Applying this protocol, we have not seen cases of postoperative sepsis.

The deteriorated bladder

This is the factor that most influences the final result. A bladder that has spent years fighting against obstruction can lose its ability to contract. If the bladder can no longer push, removing the obstruction will not restore normal voiding — the patient may be left with high residual volumes or may even need intermittent self-catheterisation.

The good news is that many bladders that appear "exhausted" recover some of their function after surgery, sometimes surprisingly so. A study involving 50,000 subjects demonstrated that bladder deterioration is progressive but that a window of opportunity exists before the damage becomes irreversible. This is why I insist that every month with a catheter is a month of potential additional bladder damage.

Important: Not all catheterised patients will have the same outcome. If the bladder is severely deteriorated, surgery will resolve the obstruction but bladder function may not fully recover. This is something we assess and explain before surgery, so that your expectations are realistic.

Raised PSA in the catheterised patient

Often, the catheterised patient has an elevated PSA. This may be due to prostate size, inflammation from the catheter, or — occasionally — an underlying prostate cancer. It is essential to rule out cancer before performing an enucleation.

At ICUA, we have developed a rapid resolution protocol for these patients: we perform a transperineal biopsy under spinal anaesthesia as an outpatient procedure, using our MRI-fusion and micro-ultrasound protocol. Our pathologist processes the samples overnight and has the result ready first thing the following morning.

If the biopsy is negative, the patient is readmitted that same day and we proceed with HoLEP. In this way, a process that at other centres can take weeks is resolved in two days. For the catheterised patient, who lives every day as an ordeal, this speed makes an enormous difference.

Act now: time is not on your side

I will be direct: if you have a permanent catheter due to prostatic obstruction, every week that passes without resolving the situation is a week of potential additional bladder deterioration. The bladder does not wait indefinitely. The sooner the obstruction is resolved, the greater the chance that the bladder will recover its function.

I have seen too many patients who arrived too late — men in their 80s who had been catheterised for years and whose bladder could no longer contract. We removed the entire adenoma, the urethra was completely clear, but the bladder simply would not push. It is a sad situation and, in many cases, one that was avoidable had action been taken sooner.

If you or a family member has a permanent catheter due to the prostate: do not accept that situation as final. In most cases it can be resolved. But time matters — every month of waiting is a month of potential bladder deterioration.

Do you have a permanent catheter and want to know if it can be resolved?

Send us your medical records. We respond within 48 hours with an initial assessment and an action plan.
📞 +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. 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

→ What Is HoLEP? A Complete Guide to Holmium Laser Enucleation of the Prostate → HoLEP Prostate Surgery: What to Expect Before, During and After → Very Large Prostate? Why En Bloc HoLEP Is the Best Option for Prostates Over 100 Grams → International Patients: Prostate Surgery in Madrid with Dr. Gómez Sancha

Robotic Urological Surgery in Madrid: Radical Prostatectomy and Beyond

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

When a patient receives a diagnosis of localised prostate cancer, one of the first things they search for is "robotic surgery". And they are right to do so: robot-assisted radical prostatectomy is today the standard surgical treatment for localised prostate cancer at most leading centres worldwide.

But not all robotic prostatectomies are the same. The surgical technique, the surgeon's experience, and the philosophy of anatomical preservation determine whether the patient, in addition to being cured of cancer, will retain urinary continence and sexual function. In this article, I explain what we do at ICUA and why our results are what they are.

What is robotic urological surgery?

Robotic surgery is not performed by a robot. It is performed by a surgeon seated at a console, controlling articulated arms that replicate his movements with precision that exceeds that of the human hand. The Da Vinci system — which is what we use at Clínica CEMTRO — offers magnified three-dimensional vision, instruments with a 360-degree range of movement, and tremor elimination. This enables more precise dissection of the structures surrounding the prostate: the erectile nerves, the urinary sphincter, and the bladder neck.

The result is a surgery that combines the oncological radicality of open surgery with minimal invasiveness: sub-centimetre incisions, minimal bleeding, a 2–3 day hospital stay, and rapid recovery.

Radical prostatectomy by lateral approach: the technique we use

Several techniques exist for performing robot-assisted radical prostatectomy. At ICUA, we use the lateral approach, a technique developed by Dr. Richard Gaston in Bordeaux, France, which differs from conventional approaches in several fundamental respects.

What does the lateral approach involve?

Rather than approaching the prostate from the front — dissecting the space of Retzius and dividing the dorsal venous complex — the lateral approach accesses the prostate from the side, through a lateral "buttonhole". This allows:

• Complete preservation of the anterior pubovesical complex: the anatomical structure connecting the bladder to the pubic bone, containing muscle fibres and nerves critical for continence and potency. In conventional techniques, this structure is partially or completely divided.
• Direct access to the seminal vesicle: without needing to mobilise anterior structures, allowing cleaner dissection of the vascular pedicles and neurovascular bundles.
• Minimal use of thermal energy: the nerves are dissected bluntly (without heat), avoiding thermal damage that can cause temporary or permanent erectile dysfunction.

The incision is longitudinal — like a "buttonhole" — less disruptive than the transverse incisions of other techniques across the fibres of the anterior complex.

The collaboration with Dr. Richard Gaston

Dr. Gaston is one of the pioneers of robotic urological surgery in Europe and the creator of this technique. Our collaboration began over 16 years ago. I learned the technique directly from him, working side by side through hundreds of procedures. It was not a weekend course or an online video — it was direct, case-by-case learning with the inventor of the procedure.

This relationship has continued over the years. Dr. Gaston has operated regularly at Clínica CEMTRO as part of our team, and together we have built the experience that underpins our published results.

Our published results: 513 patients

In 2023, we published our complete series of radical prostatectomy by lateral approach in the journal Cancers (Rodríguez Socarrás et al., 2023). The study includes 513 consecutive patients operated between January 2015 and March 2021 by two surgeons: Dr. Gaston (289 patients) and Dr. Gómez Sancha (224 patients). The primary endpoint was reproducibility — demonstrating that a second surgeon can achieve results equivalent to those of the technique's creator.

Results — Robot-assisted radical prostatectomy by lateral approach (513 patients)

Urinary continence (completely dry, no pad):
At catheter removal (day 0): 86% and 85%
At 1 month: 93% and 91%
At 1 year: 96% and 98%

Sexual potency (satisfactory intercourse):
At 3 months: 60% and 66%
At 1 year: 73% and 72%

Oncological control:
Significant positive surgical margins (>2 mm): 5.9% and 7.6% (p = 0.67 — no statistical difference)
Biochemical recurrence: 11.7% and 12%
Positive lymph nodes: 4.5% and 4.9%

Safety:
Clavien III/IV complications: 3.8% and 2.2%
Transfusion: 3.1% and 2.2%
Mean hospital stay: 2.8 and 3.3 days

No statistically significant difference between the two surgeons in any oncological, functional, or complication parameter.

These results deserve context. According to data from specialised tertiary centres, approximately half of patients report erectile dysfunction before radical prostatectomy, 80% are continent at catheter removal, and only 53% recover full sexual function. Our immediate continence rate of 85–86% (completely dry, no pad whatsoever) and potency at one year of 72–73% place our series in the upper range of published results worldwide.

What does "reproducible" mean?

It means that the results of Dr. Gómez Sancha, having learned the technique from Dr. Gaston, are statistically equivalent to those of the technique's creator. This is significant because it demonstrates that the technique does not depend on unrepeatable individual talent but on clear anatomical principles that, with appropriate training, can be taught and reproduced. The Kaplan–Meier curves for continence, potency, and biochemical recurrence show no significant difference between the two surgeons.

When is robot-assisted radical prostatectomy indicated?

Radical prostatectomy is a treatment for localised prostate cancer. It is not a treatment for benign prostatic hyperplasia (that is what HoLEP is for). The main indications are:

• Localised prostate cancer (stages T1–T2) with a life expectancy of at least 10 years.
• Selected locally advanced cancer (T3a) in appropriate patients.
• Patients who prioritise definitive treatment over active surveillance or radiotherapy.

The decision between surgery, radiotherapy, and active surveillance is complex and must be individualised. In our clinic, we use the Madrid Protocol — a combination of multiparametric MRI, fusion biopsy, and micro-ultrasound — to characterise the tumour with maximum precision before recommending treatment. This allows us to plan a personalised surgery: deciding whether to spare one or both neurovascular bundles, how much margin to take at each site, and adapting the technique to the exact tumour location.

Other robotic procedures at ICUA

Although radical prostatectomy is the most common robotic procedure, at ICUA we perform the full spectrum of robotic urological surgery:

• Robotic partial nephrectomy: for kidney tumours, preserving the maximum amount of healthy renal tissue.
• Robotic radical cystectomy: for invasive bladder cancer.
• Reconstructive procedures: pyeloplasty, ureteral reimplantation, and pelvic floor surgery.

Technology and team at Clínica CEMTRO

We operate with the latest-generation Da Vinci Xi system, with AirSeal insufflation for stable, comfortable pneumoperitoneum. The surgical team comprises surgeons with specific experience in the lateral approach, anaesthetists specialising in robotic urological surgery, and dedicated nursing staff.

Clínica CEMTRO is a leading private hospital in Madrid with over 30 years of track record and comprehensive hospital infrastructure: ICU, blood bank, advanced diagnostic imaging, and histopathology laboratory.

An important point: At ICUA, we treat both benign prostatic hyperplasia (with HoLEP) and prostate cancer (with robotic surgery). This gives us a comprehensive perspective on prostatic pathology that few centres offer. When a patient presents with urinary symptoms and we discover incidental cancer, or when a cancer patient also has obstruction from BPH, we can address both problems with the most appropriate technology and expertise for each.

Have you been diagnosed with prostate cancer and are looking for the best surgical option?

At ICUA we offer a comprehensive assessment and personalised surgery with published results.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

1. Rodríguez Socarrás M, Gómez Rivas J, Reinoso Elbers J, ..., Gastón R, Gómez Sancha F. Robot-Assisted Radical Prostatectomy by Lateral Approach: Technique, Reproducibility and Outcomes. Cancers. 2023;15:5442. DOI
2. Asimakopoulos AD, Annino F, D'Orazio A, et al. Complete Periprostatic Anatomy Preservation During RALP: The New Pubovesical Complex-Sparing Technique. Eur Urol. 2010;58:407-417. DOI
3. Rodríguez Socarrás ME, Gómez Rivas J, Cuadros Rivera V, et al. Prostate Mapping for Cancer Diagnosis: The Madrid Protocol. J Urol. 2020;204:726-733. DOI

Related articles

→ Benign Prostatic Hyperplasia (BPH): Symptoms, Diagnosis and Treatment Options → Finding the Best HoLEP Surgeon: What to Look for and Why Experience Matters → International Patients: Prostate Surgery in Madrid with Dr. Gómez Sancha

International Patients: Prostate Surgery in Madrid with Dr. Gómez Sancha

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

If you are reading this from outside Spain and considering where to have your prostate surgery, you have probably done a fair amount of research already. Perhaps you have a very large prostate and your urologist has recommended open surgery. Perhaps you have been offered a TURP but have read that retreatment is common. Or perhaps you simply want access to one of the most experienced HoLEP surgeons in the world, and your search has led you here.

At ICUA, we have been receiving patients from around the world for over 15 years. We have developed a streamlined process so that coming to Madrid for surgery is straightforward, safe, and free of surprises.

Why patients from around the world choose ICUA

The short answer: experience, technique, and results.

• Over 10,000 HoLEP procedures performed by Dr. Gómez Sancha — one of the largest individual series in the world.
• A proprietary technique published in peer-reviewed journals: en bloc enucleation with early apical release, with verifiable results in 754 consecutive patients.
• International training reference centre: over 400 urologists from 60+ countries have trained in our technique at ICUA.
• Dedicated team: multilingual coordination, preoperative video consultation, fixed all-inclusive quote before you travel.
• Clínica CEMTRO: a leading private hospital in Madrid with state-of-the-art technology.

But beyond the numbers, what our international patients value most is direct communication with the surgeon throughout the entire process. At ICUA, you speak directly with Dr. Gómez Sancha during your preoperative video consultation. Not with an intermediary, not with a call centre.

The process step by step

Step 1 — First contact and medical records
You write to us by email or WhatsApp. You send your medical records: prostate ultrasound (with volume), blood test with PSA, flowmetry if available, and any additional investigations. Our team reviews the documentation and confirms whether you are a candidate for HoLEP.

Step 2 — Video consultation with Dr. Gómez Sancha
A 20–30 minute video consultation in which we review your tests together, I explain which technique is most appropriate for your case, answer all your questions, and set realistic expectations about the outcomes.

Step 3 — Fixed quote and planning
We send you a detailed, fixed quote that includes everything: surgery, anaesthesia, hospital stay, disposable materials, histopathology, and follow-up. No hidden extras. Our coordinator, Vanesa Cuadros, helps with travel planning: surgery dates, accommodation near the clinic, and logistics.

Step 4 — Arrival in Madrid and surgery
We recommend arriving the day before surgery. The operation is performed at Clínica CEMTRO. Most patients stay one night in hospital and return to their hotel the following day with their urinary catheter in place.

Step 5 — Recovery in Madrid (5–7 days)
The catheter is removed at a follow-up visit a few days later. We perform a control flowmetry and ensure everything is in order before you return home. Madrid is a comfortable city for recovery: good weather, excellent food, and your hotel will be minutes from the clinic.

Step 6 — Remote follow-up
Once you are home, we follow up by video consultation. We provide a comprehensive clinical report in your language and a detailed medical invoice to facilitate reimbursement from your insurer or healthcare system.

Practical information

Getting to Madrid

Madrid-Barajas Airport has direct flights to and from all major European cities, the Middle East, Latin America, and many destinations in Asia and North America. Clínica CEMTRO is in north-west Madrid, well connected by public transport and surrounded by several hotels within a short distance. We can recommend nearby accommodation with special rates for patients.

Languages

Dr. Gómez Sancha is fluent in Spanish and English. Coordination with Vanesa Cuadros and the ICUA team is available in Spanish, English, and for many patients, Portuguese. For other languages, we arrange translation assistance as needed.

Cost and billing

The quote is fixed and in euros. It includes everything needed for surgery and initial postoperative follow-up. We issue a detailed medical invoice and a comprehensive clinical report to facilitate reimbursement in your country. The cost of HoLEP in Spain is significantly lower than in the United States, the United Kingdom, Switzerland, or the Gulf states, with outcomes comparable to or better than leading international centres.

Do I need a visa?

Citizens of the European Union, the United Kingdom, the United States, Canada, Australia, Japan, and most Latin American countries do not need a visa for stays of up to 90 days in Spain. For patients who do require one, we provide medical documentation to support the visa application.

Common questions from international patients

How long do I need to stay in Madrid?

Plan for 5–7 days in total: arrive the day before surgery, one night in hospital, and 3–5 days at a hotel while we monitor your recovery and remove the catheter. Most patients fly home comfortably within a week of surgery.

Can my partner or family come with me?

Absolutely. Many patients travel with their partner. Madrid offers plenty for a companion to do while you recover — it is one of Europe's great cities for food, culture, and walking. Some couples treat the trip as a short holiday once the medical part is complete.

What if something goes wrong after I return home?

Complications after HoLEP are rare, but we are always available. You will have direct contact with our team by email and WhatsApp. If a situation arises that requires in-person attention, we coordinate with a local urologist in your area or arrange your return to Madrid if necessary. In over 15 years of treating international patients, this has been an exceptional occurrence.

My prostate is very large — can I still have HoLEP instead of open surgery?

This is one of the most common reasons international patients come to us. Many have been told they need open surgery because their prostate is over 100, 150, or even 200 grams. In our experience, prostate size is not a limitation for HoLEP — in fact, larger prostates often benefit the most from enucleation. Our published series includes prostates well over 200 grams, all operated endoscopically with excellent outcomes.

A personal note: Receiving a patient who has travelled from another country to be operated by me is an enormous responsibility. That person has placed their trust not only in my medical judgement but has also left their home, their family, and their support network to put themselves in my hands. I take that trust very seriously, and the care our international patients receive reflects that commitment.

Are you outside Spain and want to know if HoLEP is right for you?

Send us your medical records and we will respond within 48 hours with an initial assessment.
📞 +34 91 435 28 44 · ✉ icua@icua.es
WhatsApp: +34 91 435 28 44

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. 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

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 → Finding the Best HoLEP Surgeon: What to Look for and Why Experience Matters → How Much Does HoLEP Surgery Cost? Factors That Affect the Price

En Bloc HoLEP with Early Apical Release: The Gómez Sancha Technique

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

When a patient asks me what the operation involves, I draw an orange. Men are born with the peel — the prostatic capsule — and from the age of 30, the segments inside gradually grow. Since the urethra runs through the centre, it becomes progressively obstructed. What we do in an enucleation is remove the segments and leave the peel clean.

But how those segments are removed matters a great deal. Cutting them into pieces is not the same as peeling them out in one go. En bloc enucleation with early apical release is the technique I have developed and refined over two decades and more than 10,000 procedures. In this article, I explain what makes it different and why I believe it delivers better outcomes.

What does "en bloc" mean in prostate surgery?

In conventional holmium laser enucleation (HoLEP), the prostatic adenoma is typically divided into two or three lobes. Deep incisions are made to separate the lobes, and each fragment is then dissected from the capsule individually. It is a technique that works, but it involves multiple cuts through tissue and working with several separate pieces.

In en bloc enucleation, the adenoma is removed in a single piece — like peeling an entire orange, keeping all the segments attached. There are no incisions to fragment the adenoma. The surgeon peels the entire piece circumferentially from the capsule until it is freed as a whole into the bladder, where it is morcellated for extraction.

The advantages of this approach are several: less bleeding because the large vessels between the lobes are not transected, better tissue orientation for the pathologist (important if incidental cancer is found), and — most critically — more precise control of the urinary sphincter, the structure responsible for continence.

The evolution: from vaporisation to en bloc

This technique did not appear overnight. It was the result of an evolution that began over 20 years ago.

My beginnings in laser surgery were with GreenLight laser vaporisation in 2003. We quickly recognised the advantages of the endoscopic approach — minimal invasiveness, rapid recovery, low complication rates — but also understood the limits of vaporisation in large prostates.

The evolution was gradual: conventional vaporisation → anatomical vaporisation (identifying the capsule to take the vaporisation to that depth) → hybrid technique of lateral vaporisation with middle lobe enucleation → progressively less vaporisation and more enucleation → complete en bloc enucleation with GreenLight laser (GreenLEP). We published this evolution in 2015 (Gómez Sancha et al., World J Urol).

In 2011, I began working with the holmium laser. I initially learned the three-lobe technique, but quickly sought to reproduce the en bloc approach I had been performing for several years with the green laser. This led to the publication of our technique in 2019 (Saitta, Gómez Sancha et al., World J Urol): an incision-free en bloc enucleation with early apical release and sphincteric mucosa preservation, initially in 137 patients.

Early apical release: why it makes the difference

This is the core of what differentiates this technique from other enucleation methods. To understand why it matters, a brief lesson in anatomy is needed.

The external sphincter and its mucosa

The external urinary sphincter is the muscle that maintains continence — the one that allows a man to control when he urinates and when he does not. This sphincter is lined by a mucosa, a layer of tissue that functions as a watertight seal. Without this mucosa intact, the sphincter can be incontinent for weeks or months until the mucosa regenerates.

In many enucleation techniques, the apical dissection (the lowest part of the adenoma, just above the sphincter) is left until the end. The problem is that as the adenoma is peeled from above downwards, traction is generated on the sphincter. This traction strips the sphincteric mucosa, creating what is known as the "mucosal curtain" — a flap of tissue that indicates the sphincter's lining has been damaged.

What makes early apical release different

In our technique, the first step is to identify the "white line" — the boundary between the adenoma apex and the external sphincter. At that point, we release the adenoma from the sphincter at the beginning of the procedure, not at the end. By separating the adenoma from the sphincter early, we achieve three things:

• We eliminate traction: when dissecting the rest of the adenoma circumferentially, we are no longer pulling on the sphincter because it has already been freed.
• We preserve the sphincteric mucosa: without traction, the mucosa lining the sphincter remains intact, maintaining its sealing function.
• We improve visibility: with the apex released from the outset, the surgical field throughout the remainder of the procedure is excellent.

Why does the sphincteric mucosa matter? A sphincter without its mucosa is like a tap without a washer — it may function, but it leaks. A de-epithelialised sphincter can be incontinent for weeks or months until the mucosa regenerates. This is the principal factor explaining the differences in early incontinence between enucleation techniques. The sphincteric mucosa is now recognised as an integral component of the continence mechanism.

No incisions: another key principle

Many enucleation techniques begin with deep incisions into the adenoma — at the 5 and 7 o'clock positions, or at 12 o'clock — to separate the lobes. These incisions transect vessels and cause bleeding, and divide the adenoma into fragments that must then be dissected separately.

In the en bloc technique, there are no initial incisions. The dissection is circumferential, peeling the adenoma from the capsule like peeling a fruit. The laser is used to coagulate feeding vessels (the pedicles) and to cut fibrous tracts when necessary, but the bulk of the separation is mechanical, with the tip of the endoscope.

The result is an adenoma removed in a single piece, with less bleeding and — crucially — perfectly orientable for the pathologist. If incidental cancer is present (which occurs in 5–8% of cases), the pathologist can assess the margins with the same precision as a conventional surgical specimen.

Published results

Our most recent series, published in World Journal of Urology in 2025, includes 754 consecutive patients operated by a single surgeon using this technique:

754-patient series — En Bloc HoLEP with early apical release

Efficiency: 3.1 g/min in large prostates (≥120 g) · Mean operative time 47 min (initial 137-patient series)

Continence (stress incontinence at 6 months): 0.15% for prostates <120 0.9="" br="" for="" g="" prostates="">
Functional outcomes: Qmax 24–28 ml/s postoperatively · PSA reduction 93–94%

Safety: Transfusion rate <1 div="" rate="" retreatment="">

To put the continence figure in context: a stress incontinence rate of 0.15% at six months means that of every 1,000 patients operated with prostates under 120 grams, only 1 or 2 would need a pad for stress incontinence at six months after surgery.

The REAP registry, a global multicentre registry of 6,193 patients operated by multiple surgeons using enucleation techniques with early apical release, confirmed that the principle of early apex release is associated with low incontinence rates even when performed by different surgeons at different centres.

Reproducibility: a technique taught worldwide

Any surgical technique, however good, has limited value if only one person can perform it. That is why reproducibility is a fundamental criterion.

Since 2007, we have received over 600 visiting urologists from more than 60 countries at ICUA to train in this technique. The training programme includes direct operating theatre observation, tutored practice, and subsequent follow-up. Many of these surgeons have implemented the technique at their own centres with published results.

In a published series of 500 patients with learning curve analysis (Wenk et al., 2024), it was demonstrated that the en bloc technique is reproducible and that the learning curve, when training is structured, is shorter than traditionally attributed to HoLEP.

It is not an easy technique — it requires specific training and sufficient case volume. But it is teachable and reproducible, and that is what matters.

For the patient: what does all this mean for you?

If you have read this far, you are probably an informed patient who researches before making a decision, or a urologist evaluating technical options. Either way, the key point is this:

Not all HoLEP procedures are the same. The surgical technique, the principles guiding the operation, and the surgeon's experience determine the outcomes in continence, complications, and the likelihood of needing reoperation. En bloc enucleation with early apical release and sphincteric mucosa preservation is the product of over 20 years of technical evolution, more than 10,000 cases, and a clear philosophy: remove the entire adenoma while maximally protecting the structures of continence.

Want to be operated using this technique?

At ICUA we perform this surgery daily. Request a consultation to evaluate your case.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

1. Saitta G, Becerra JEA, Del Álamo JF, Gómez Sancha F, et al. 'En Bloc' HoLEP with early apical release in benign prostatic hyperplasia. World J Urol. 2019;37:2451-2458. PubMed
2. Iscaife A, Rodríguez Socarrás M, Talizin TB, Gómez Sancha F, et al. Contemporary results of En Bloc HoLEP for large prostates — a single surgeon series of 754 patients. World J Urol. 2025;43:401. PubMed
3. Gómez Sancha F, Rodríguez Socarrás M, Zorn K, et al. Common trend: move to enucleation — is there a case for GreenLEP? World J Urol. 2015;33:539-547. DOI
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. Wenk B, et al. En bloc HoLEP learning curve in 500 consecutive patients. World J Urol. 2024. PubMed
6. Gauhar V, et al. Early apical release during endoscopic enucleation of the prostate (EAR) — 4392 patients. Urology. 2024. DOI

Related articles

→ What Is HoLEP? A Complete Guide to Holmium Laser Enucleation of the Prostate → Finding the Best HoLEP Surgeon: What to Look for and Why Experience Matters → Very Large Prostate? Why En Bloc HoLEP Is the Best Option for Prostates Over 100 Grams → ICUA Training Programme: Surgeons from 60 Countries Trained in This Technique

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