Mechanisms of Prostatic Vascular Regression Induced by 5-Alpha Reductase Inhibitors: From Molecular Pathways to Surgical Benefit

Abstract

5-alpha reductase inhibitors (5-ARIs), including finasteride and dutasteride, are well established in the medical management of benign prostatic hyperplasia (BPH). Beyond their effects on prostate volume, 5-ARIs exert a profound antiangiogenic effect on prostatic tissue through multiple interconnected mechanisms. By inhibiting the conversion of testosterone to dihydrotestosterone (DHT), 5-ARIs suppress the expression of vascular endothelial growth factor (VEGF), reduce microvessel density (MVD), induce endothelial cell apoptosis, and modulate additional proangiogenic mediators including hypoxia-inducible factor-1α (HIF-1α). These effects translate into measurable clinical benefit, particularly in reducing perioperative bleeding during transurethral resection of the prostate (TURP), controlling BPH-related haematuria, and treating refractory hematospermia. The same antiangiogenic rationale may also be relevant to modern enucleation procedures. Importantly, the vascular regression induced by 5-ARIs occurs rapidly — within as few as two weeks — preceding volumetric gland reduction. This review synthesises the current evidence on the molecular mechanisms underlying 5-ARI-induced prostatic devascularisation, with emphasis on its translational relevance to surgical and clinical urological practice.

1. Introduction

Benign prostatic hyperplasia (BPH) is one of the most prevalent urological conditions affecting aging men, with histological evidence present in up to 80–90% of men in their seventh and eighth decades of life ^[1]. The 5-alpha reductase inhibitors (5-ARIs) finasteride and dutasteride represent a cornerstone of medical therapy for BPH, acting by blocking the intraprostatic conversion of testosterone to dihydrotestosterone (DHT), the principal androgen responsible for prostate growth and development ^[2][3].

While 5-ARIs are primarily recognised for their ability to reduce prostate volume by 20–30% and decrease the risk of acute urinary retention and BPH-related surgery ^[4][5], an increasingly well-characterised but underappreciated effect is their capacity to reduce prostatic vascularity. This antiangiogenic property has direct clinical relevance: a recent meta-analysis of 30 randomised controlled trials by Hehir et al. (2026) demonstrated that preoperative 5-ARI administration significantly reduces intraoperative blood loss (mean difference −82.58 mL), haemoglobin drop (−0.90 g/dL), blood transfusion rates (OR 0.31), and operative time during TURP ^[6].

The purpose of this review is to delineate the molecular and cellular mechanisms through which 5-ARIs achieve prostatic vascular regression, and to discuss the translational implications for surgical practice — including their potential relevance to modern enucleation techniques.

2. The DHT–VEGF Axis: The Central Mechanism

The primary mechanism through which 5-ARIs reduce prostatic vascularity is the disruption of the androgen-driven VEGF signalling pathway. Under physiological and hyperplastic conditions, DHT acts as a potent stimulator of VEGF expression in prostatic stromal and epithelial cells ^[7][8]. VEGF, in turn, is the dominant proangiogenic factor responsible for driving neovascularisation within the hyperplastic prostate ^[9].

The intraprostatic concentration of DHT is approximately five-fold higher than that of testosterone, owing to the activity of 5-alpha reductase ^[10][11]. Finasteride, which selectively inhibits the type 2 isoenzyme, reduces serum DHT by approximately 70%, while dutasteride, a dual inhibitor of types 1 and 2, achieves suppression exceeding 90–95% ^[12][13]. This reduction in intraprostatic DHT leads to a significant downregulation of VEGF expression in prostatic tissue.

Pareek et al. (2003) demonstrated that finasteride-treated patients undergoing TURP exhibited significantly lower VEGF expression and microvessel density (MVD) in suburethral prostatic tissue compared to untreated controls (p < 0.05) ^[14]. Importantly, the reduction in VEGF was most pronounced in the suburethral compartment, precisely the tissue most relevant to perioperative bleeding during transurethral procedures.

Häggström et al. (1999) had previously shown in a castration model that testosterone directly induces VEGF synthesis in the ventral rat prostate, establishing the mechanistic link between androgen signalling and prostatic angiogenesis ^[15]. The 5-ARIs replicate this effect pharmacologically by reducing DHT without complete androgen deprivation.

3. Microvessel Density Reduction: Evidence from Human Studies

Multiple clinical studies have confirmed that 5-ARI treatment reduces MVD in human prostatic tissue. Hochberg et al. (2002) first reported significantly decreased suburethral MVD in finasteride-treated prostates using CD34 immunohistochemistry ^[16]. This finding was subsequently confirmed by Memis et al. (2008), who demonstrated reduced MVD specifically in the suburethral zone after 4 weeks of finasteride therapy ^[17].

A critical finding from Donohue et al. (2005) was that even a short 2-week course of finasteride can significantly reduce prostatic MVD and VEGF expression in a randomised, placebo-controlled setting. In 64 patients randomised to finasteride 5 mg or placebo before TURP, MVD was 60 vs 71 and VEGF scores were 47 vs 61 (p < 0.01 and p < 0.001, respectively) ^[18b]. This rapid effect — which precedes meaningful volumetric gland reduction — indicates that the antiangiogenic mechanism of 5-ARIs is independent of their gland-shrinking properties and represents a primary pharmacological effect.

The meta-analysis by Hehir et al. pooled data from multiple RCTs and confirmed a significant reduction in MVD (MD = −6.18 vessels/mm³, p < 0.001) and VEGF expression (MD = −3.25, p < 0.001) in 5-ARI-treated specimens, providing level 1 evidence for this effect ^[6].

4. Endothelial Cell Apoptosis and Vascular Regression

Beyond the suppression of proangiogenic signalling, 5-ARIs actively promote regression of existing prostatic microvasculature through induction of apoptosis. Sutton et al. (2006) demonstrated that finasteride treatment leads to a significant increase in the apoptotic index (by TUNEL assay) and reduced MVD (Factor VIII staining) in prostatic specimens from BPH patients treated for 1–12 months compared to untreated controls (p < 0.01) ^[19].

The same study showed that finasteride inhibits prostate epithelial cell adhesion in vitro, suggesting an additional mechanism by which the drug disrupts the structural integrity of prostatic tissue and its vascular support network. The authors proposed that finasteride targets prostate vascularity through a dual mechanism: inducing apoptosis in both endothelial and epithelial compartments, and inhibiting cell–cell adhesion interactions necessary for vascular maintenance ^[19].

Rittmaster et al. (1995) provided earlier evidence of finasteride-induced apoptosis and atrophy in the ventral rat prostate, demonstrating that 5-ARI treatment leads to ductal atrophy through programmed cell death rather than simple quiescence ^[20]. This apoptotic process in the epithelial and stromal compartments reduces the metabolic demand of prostatic tissue, further diminishing the paracrine signalling that sustains the microvascular network.

5. Modulation of HIF-1α and Additional Angiogenic Mediators

Lekas et al. (2006) evaluated the effects of finasteride on hypoxia-inducible factor-1α (HIF-1α), VEGF, and MVD in resected prostatic tissue from BPH patients. They found statistically significant reductions in all three parameters in finasteride-treated specimens compared to controls ^[21]. HIF-1α is a master transcription factor that responds to tissue hypoxia by upregulating a suite of proangiogenic genes, including VEGF, fibroblast growth factor (FGF), and platelet-derived growth factor (PDGF) ^[22].

The reduction of HIF-1α by finasteride suggests that 5-ARIs may interrupt a broader hypoxia-driven angiogenic programme in the hyperplastic prostate, rather than acting solely through VEGF suppression. In hyperplastic prostatic tissue, the expanding adenoma creates areas of relative hypoxia that stimulate HIF-1α-mediated neovascularisation. By simultaneously reducing both the tissue mass (and therefore hypoxic demand) and the direct androgen-driven VEGF pathway, 5-ARIs achieve a synergistic antiangiogenic effect.

Ku et al. (2009) extended these findings to dutasteride, demonstrating similar reductions in HIF-1α and VEGF expression in both rat and human prostatic tissue, supporting a class effect rather than a finasteride-specific phenomenon ^[23].

Table 1

Study / Year	Design	Treatment	Duration	N	Key findings	Compartment	Key p-value	Ref
Pareek et al. 2003	Observational comparative	Finasteride 5 mg	Variable (pre-TURP)	~24	↓ VEGF expression and ↓ suburethral MVD (CD34)	Suburethral	p < 0.05	[14]
Hochberg et al. 2002	Comparative	Finasteride	Variable	~20–30	↓ Suburethral MVD (CD34) in haematuria/BPH patients	Suburethral	Significant	[16]
Memis et al. 2008	Prospective comparative	Finasteride 5 mg	4 weeks	30	↓ Significant suburethral MVD vs controls	Suburethral	Significant	[17]
Donohue et al. 2005	Placebo-controlled RCT	Finasteride 5 mg	2 weeks	64	↓ MVD (60 vs 71) and ↓ VEGF (47 vs 61) in post-TURP tissue	Prostatic (post-TURP)	MVD p < 0.01; VEGF p < 0.001	[18b]
Lekas et al. 2006	Comparative	Finasteride	Variable	Not spec.	↓ HIF-1α, ↓ VEGF, ↓ MVD in resected tissue	Prostatic	Significant	[21]
Sutton et al. 2006	Comparative + in vitro	Finasteride	1–12 months	27	↑ Apoptotic index (TUNEL), ↓ MVD (Factor VIII), ↓ cell adhesion	Prostatic	p < 0.01	[19]
Ku et al. 2009	Comparative (rat + human)	Dutasteride	Variable	N/A (mixed model)	↓ HIF-1α and ↓ VEGF in human and rat prostatic tissue	Prostatic	Significant	[23]
Hehir et al. 2026	Meta-analysis (30 RCTs)	5-ARIs (fin/dut)	Variable (incl. 2 wk)	2974	↓ MVD (MD −6.18 vessels/mm³); ↓ VEGF (MD −3.25)	Prostatic (pooled)	p < 0.001 both	[6]

Table 1. Summary of key evidence on 5-ARI-induced reduction of microvessel density (MVD) and VEGF expression in human prostatic tissue. MD = mean difference.

[18b] Donohue JF, et al. Randomized, placebo controlled trial showing that finasteride reduces prostatic vascularity rapidly within 2 weeks. BJU Int. 2005;96(9):1319–1322.

6. A Bidirectional Model: Tissue Involution and Vascular Regression

The relationship between prostatic tissue involution and vascular regression is bidirectional. On one hand, reduction of DHT leads to epithelial and stromal apoptosis, which decreases the metabolic demand and paracrine signalling that sustain the microvascular bed ^[20][24]. On the other hand, microvascular regression reduces the trophic support available to the glandular tissue, further accelerating involution ^[19].

This positive feedback loop explains why the antiangiogenic effects of 5-ARIs are detectable before significant volumetric reduction occurs: endothelial cell apoptosis is a relatively rapid process (days to weeks), whereas glandular involution requires sustained androgen suppression over months ^[18b][25]. The clinical implication is that even short preoperative courses of 5-ARIs (as little as 2 weeks) may confer haemostatic benefit during surgery, as confirmed by the meta-analytic data ^[6].

It is worth noting that 5-alpha reductase inhibition reduces prostatic size by 20–30% through induction of apoptosis, histologically manifested as ductal atrophy, and diminishes the number of blood vessels through VEGF reduction ^[25]. This dual action — volumetric and vascular — distinguishes 5-ARIs from pure alpha-blockers, which provide symptomatic relief without altering the underlying tissue biology.

7. Application in Hematospermia: Extension of the Antiangiogenic Rationale

An additional clinical application that directly reflects the antiangiogenic properties of 5-ARIs is the treatment of hematospermia (hemospermia). Although hematospermia is most commonly a benign, self-limiting condition, persistent or recurrent cases can cause significant patient distress and pose a diagnostic challenge ^[27]. The seminal vesicles and prostatic urethra share the same androgen-dependent vascular microenvironment as the transition zone; consequently, the mechanisms of MVD reduction and VEGF suppression described above are equally relevant to this clinical scenario.

Badawy et al. (2012) conducted a prospective, placebo-controlled study evaluating finasteride 5 mg daily for 3 months in 24 patients with idiopathic refractory hematospermia. In the finasteride group, 66.7% of patients experienced complete remission of bleeding episodes within 2–5 weeks, confirmed objectively by semen analysis. In contrast, only 25% of placebo-treated patients showed improvement, and those who did still demonstrated significant residual erythrocytes on microscopy (>50 RBC/HPF). No recurrence was observed during the 3-month treatment period in responders ^[28].

This rapid response — within weeks, not months — mirrors the timeline of MVD reduction observed in the preoperative TURP studies, reinforcing the concept that the antiangiogenic effect of 5-ARIs precedes gland involution and operates as the primary mechanism of bleeding control.

Zhang et al. (2014) reported on the combination of transurethral seminal vesiculoscopy (TUSV) with perioperative finasteride (5 mg/d for 2 weeks pre- and post-procedure) in 32 patients with recurrent hematospermia. The combined approach allowed both diagnostic evaluation and treatment, with finasteride providing a pharmacological reduction in tissue vascularity that complemented the endoscopic intervention ^[29].

In the management algorithms for hematospermia, 5-ARIs are now positioned as a pharmacological option for persistent cases after exclusion of infection and malignancy, particularly when the bleeding source is prostatic or seminal vesicular in origin ^[30][31]. The rationale is mechanistically identical to the perioperative use in TURP: by reducing DHT-driven VEGF expression and MVD in the prostatic and periprostatic vasculature, finasteride diminishes the fragility and density of submucosal vessels prone to rupture during erection and ejaculation.

A noteworthy paradox exists: finasteride has also been reported as a rare cause of hematospermia, particularly in younger men taking low-dose (1 mg) finasteride for androgenetic alopecia ^[32]. This apparent contradiction may reflect the transitional vascular remodelling that occurs during the initial phase of treatment, before a new steady-state of reduced vascularity is established. The clinical significance of this paradoxical effect appears to be minimal and self-limiting.

8. Clinical and Surgical Implications

Preoperative optimisation for TURP: The meta-analysis by Hehir et al. (2026) provides robust evidence that preoperative 5-ARI administration reduces intraoperative blood loss, transfusion requirements, irrigation volume, and operative time during TURP. Even short courses of 2 weeks appear to be effective, making this a practical preoperative intervention ^[6].

Management of BPH-related haematuria: Kearney et al. demonstrated that finasteride effectively controls gross haematuria secondary to BPH, with 94% of patients experiencing improvement and 77% achieving complete resolution, regardless of anticoagulation status ^[26]. This effect is mediated by the MVD reduction in suburethral prostatic tissue.

Potential relevance to enucleation procedures: While the current evidence is largely based on TURP, the antiangiogenic mechanisms of 5-ARIs should theoretically benefit any procedure that involves transurethral dissection of prostatic tissue. During holmium laser enucleation of the prostate (HoLEP) and other enucleation techniques, bleeding from the capsular plane is a significant intraoperative consideration. Whether preoperative 5-ARI therapy confers similar haemostatic advantages during enucleation as it does during resection remains an important area for future investigation.

Patients on anticoagulation: 5-ARIs may be particularly valuable in patients who require ongoing anticoagulant or antiplatelet therapy and are at increased risk of perioperative bleeding. The reduction in tissue vascularity may partially offset the systemic haemostatic impairment in these patients.

Figure 1. Integrated Model of 5-ARI-Induced Prostatic Vascular Regression

Figure 1. Three-level model of 5-ARI-induced prostatic devascularisation: molecular pathways, tissue-level effects, and clinical outcomes.

9. Conclusion

5-alpha reductase inhibitors reduce prostatic vascularity through a cascade of interconnected mechanisms: suppression of DHT-driven VEGF expression, reduction of microvessel density, induction of endothelial and epithelial apoptosis, and modulation of the broader HIF-1α-mediated angiogenic programme. These effects occur rapidly, with measurable MVD reduction within 2 weeks of treatment, and are supported by level 1 evidence from pooled randomised controlled trials.

Understanding these mechanisms is important not only for optimising perioperative management in BPH surgery but also for informing clinical decision-making regarding the timing and duration of preoperative 5-ARI therapy. Future research should evaluate whether these antiangiogenic benefits extend to modern enucleation techniques, and whether specific patient subgroups (e.g., those on anticoagulation, or with highly vascularised prostates) derive disproportionate benefit from preoperative 5-ARI administration.

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[3] Traish AM, Mulgaonkar A, Giordano N. The dark side of 5α-reductase inhibitors' therapy. Korean J Urol. 2014;55(6):367–379. PubMed

[4] McConnell JD, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of BPH. N Engl J Med. 2003;349(25):2387–2398. PubMed

[5] Roehrborn CG, et al. Efficacy and safety of dutasteride in men with BPH. Urology. 2002;60(3):434–441. PubMed

[6] Hehir CM, et al. The role of 5-alpha reductase inhibitors in TURP: a meta-analysis of RCTs. BJU Int. 2026. doi: 10.1111/bju.70117. PubMed

[7] Chislett B, et al. 5-ARI use in prostatic disease and beyond. Transl Androl Urol. 2023;12(3):487–505. PMC

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[9] Ferrara N. Role of VEGF in the regulation of angiogenesis. Kidney Int. 1999;56(3):794–814. PubMed

[10] Bruchovsky N, Wilson JD. The conversion of testosterone to 5α-DHT by rat prostate. J Biol Chem. 1968;243(8):2012–2021. PubMed

[11] Carson C, Rittmaster R. The role of DHT in BPH. Urology. 2003;61(4 Suppl 1):2–7. PubMed

[12] Clark RV, et al. Marked suppression of DHT by dutasteride. J Clin Endocrinol Metab. 2004;89(5):2179–2184. PubMed

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[17] Memis A, et al. Effect of finasteride on suburethral prostatic MVD in hematuria patients. Urol Int. 2008;80(2):177–180. PubMed

[18] Donohue JF, et al. TURP and bleeding: RCT of finasteride for decreasing blood loss. J Urol. 2002;168(5):2024–2026. PubMed

[18b] Donohue JF, et al. Finasteride reduces prostatic vascularity rapidly within 2 weeks. BJU Int. 2005;96(9):1319–1322. PubMed

[19] Sutton M, et al. Finasteride targets prostate vascularity by inducing apoptosis and inhibiting cell adhesion. Prostate. 2006;66(11):1194–1202. PubMed

[20] Rittmaster RS, et al. Evidence for atrophy and apoptosis in the rat prostate with finasteride. Endocrinology. 1995;136(2):741–748. PubMed

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Training the Next Generation: En Bloc HoLEP Visitors from Ukraine, Greece and Colombia

Training the Next Generation: Visitors from Ukraine, Greece and Colombia

One of the most rewarding aspects of what we do at ICUA, Clínica CEMTRO, is welcoming urologists from around the world who want to learn en bloc HoLEP.

Today we had visitors from Ukraine, Greece and Colombia — three different healthcare systems, three different surgical traditions, one shared goal: mastering anatomical enucleation. We have scheduled 6 holeps today and 6 HoLEPs tomorrow, to try to provide a balanced experience and enough cases. Tipically we can do 6 HoLEPs from 3 to 9 pm if there is no extreme case. Prostate sizes varied from 30 to 120 cc. 

The Quanta Magneto laser and our standardized training approach allow us to transfer years of experience in a structured, hands-on environment. Surgeons observe live cases, discuss technique in real time, and understand the nuances of capsular plane navigation that make en bloc enucleation reproducible.

This is how HoLEP adoption scales globally — not through marketing campaigns, but through one-on-one mentorship. Every surgeon who leaves our training programme takes the technique home to their patients.

Dr. Fernando Gómez Sancha — Medical Director, ICUA, Clínica CEMTRO, Madrid

The $30 Billion Question: Why Are Patients Steered Toward Less Durable BPH Treatments?

By Dr. Fernando Gómez Sancha, MD
Urologist & World Expert in En Bloc HoLEP | 10,000+ Procedures | 50 Countries

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"If a treatment exists with a 4.4% retreatment rate at five years, and another exists with a 14-17% retreatment rate at the same timepoint, why are patients not always offered the choice? The answer has less to do with medicine than with money."

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Introduction: A Question Worth $30 Billion

Imagine you are told you need surgery for benign prostatic hyperplasia (BPH) — the non-cancerous enlargement of the prostate that eventually affects the majority of men over 60. Your urologist presents you with two broad categories of treatment. One group of procedures has a retreatment rate of 14-17% within five years, meaning roughly one in six patients will need another operation. The other approach carries a retreatment rate of just 4.4% — three to four times more durable.

The question is not which you would choose if given full information. The question is: why are so many patients never given that full information?

After performing more than 10,000 en bloc holmium laser enucleation of the prostate (HoLEP) procedures and training urologists in over 50 countries, I have watched the same patterns repeat across healthcare systems — from the United States to Japan, from Germany to Brazil. The issue is not individual bad actors. It is a structural misalignment built into the medical device industry, and patients deserve to understand it.

This is not a conspiracy theory. It is a documented, multi-layered system of influence that shapes what treatments get recommended, what research gets funded, what gets taught at congresses, and ultimately what options patients are offered in the consulting room. The data tells this story better than I can.

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The Economic Context: Follow the Money

The global BPH device market is worth more than $30 billion annually and is growing. Within that market, a striking divide exists between two business models: those that generate recurring revenue per procedure, and those that do not.

The Recurring Revenue Model

• Rezum (Boston Scientific, market cap ~$16.7 billion): Uses water vapour thermal therapy delivered through single-use needle cartridges. Every procedure requires new disposable components, generating direct per-case revenue for the manufacturer.

• UroLift (Teleflex, ~$3.05 billion): Uses permanent implants — small titanium devices that hold the enlarged prostate tissue aside. Each procedure requires multiple implants, each one a revenue event. In a telling development, Teleflex announced in late 2025 the divestiture of its entire Interventional Urology portfolio — including UroLift, Barrigel, and related products — to Intersurgical, just eight years after acquiring NeoTract (UroLift's maker) for $725 million. Sales had not met expectations, and CMS had cut reimbursement rates for office-based UroLift procedures by 19-21%. When the manufacturer itself exits at a loss, the market has spoken.

• Aquablation (PROCEPT BioRobotics, ~$224 million market cap but growing at +65% annually): Requires a robotic system purchase and ongoing disposables for every procedure. High upfront capital cost, then recurring revenue.

The Non-Recurring Model

• HoLEP / Laser Enucleation: Requires a holmium laser — a capital purchase that, properly maintained, lasts years and serves thousands of patients. There are no significant proprietary consumables. Once the laser is purchased, the manufacturer's revenue relationship with that hospital is essentially over.

The financial implication is stark: HoLEP is structurally unprofitable for the medical device industry. There is no business incentive to promote it, fund studies of it, or cultivate opinion leaders around it. The absence of commercial pressure does not make HoLEP better medicine — but the presence of commercial pressure around competing technologies absolutely shapes how they are marketed, studied, and ultimately recommended.

Pull Quote: "The medical device industry spends billions ensuring physicians hear about treatments that generate recurring revenue. Treatments that don't — like HoLEP — are left to promote themselves on merit alone."

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20 Mechanisms of Industry Influence

The influence of commercial interests on medical practice is well-documented in the literature. What follows is not speculation — each mechanism has been described in peer-reviewed publications, regulatory filings, or confirmed by industry insiders. They are organized into five categories.

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Category A: Direct Financial Relationships

1. Consulting fees and advisory boards. Device companies pay surgeons — often among the most respected in their fields — to sit on advisory boards, provide "input" on product development, and attend annual meetings. These relationships create a durable, if subtle, sense of loyalty and alignment.

2. Speaker honoraria. Paid speaking engagements at congresses and CME events place commercially motivated information in the mouths of credible physicians. The content may be factually accurate while being curated to emphasize benefits and minimize risks.

3. Proctoring fees. This is perhaps the most insidious mechanism. Device companies pay expert surgeons to travel and teach their technique at other institutions. The surgeon is compensated. The institution receives "training." But the entire programme exists to drive adoption of a revenue-generating procedure. It is sales, dressed as education.

4. Research grants with strings attached. Industry-funded research is not inherently corrupt — but the terms of funding agreements frequently include provisions that give sponsors influence over publication, data access, and framing of results. A surgeon who accepts device company funding for a study is not automatically biased, but the structural pressures are real.

5. Stock options and equity stakes. Some KOLs (Key Opinion Leaders) hold equity in the companies whose devices they champion. In the US, these relationships must be disclosed; in many other countries, they need not be.

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Category B: Shaping the Evidence

6. Industry-funded trials designed to support the product. A 2020 study in the Journal of Sexual Medicine (Bouhadana et al., funded by PROCEPT BioRobotics) concluded that ejaculation preservation is patients' number one priority when choosing BPH treatment. This finding — legitimate in isolation — happens to be precisely Aquablation's commercial differentiator. The study was designed to produce a finding that served a marketing purpose, then published in a peer-reviewed journal, lending it scientific credibility.

7. "Data torture" — choosing favorable endpoints. Defining a "responder" as any patient who improves by just 3 points on the IPSS (International Prostate Symptom Score) sounds rigorous. But a 3-point improvement — from 23 to 20 — represents a clinically marginal change. When industry-funded studies use such lenient thresholds, "response rates" of 80-90% become possible for treatments that provide minimal functional improvement.

8. Professional medical writers who know which endpoints to select. A sophisticated body of commercial medical writing exists specifically to present clinical data in the most favorable light. Statistical significance is achieved by choosing the right subgroups, timepoints, and comparators. This is legal, peer-reviewed, and largely invisible.

9. Short follow-up periods. A 12-month result is not a treatment outcome — it is a snapshot. BPH is a chronic condition. Patients live with the consequences of their treatment for decades. Industry trials routinely follow patients for 12-24 months and publish results during this window, before retreatment rates become apparent.

10. The iTind example. The temporary implantable nitinol device (iTind) was marketed with the headline: "safe and effective up to 12 months." At 48 months, the surgical retreatment rate was 11.1%. Those who received the device at 12 months were told it worked. At four years, one in nine needed another procedure. The 12-month data was not false — it was selectively true.

11. Cherry-picking. A Rezum marketing flyer has cited a "4.4% surgical retreatment rate" compared to "13% for TURP." What the same flyer did not mention: the objective flow rate (Qmax) improvement after Rezum is significantly lower than after HoLEP — matched pair analysis shows HoLEP achieving a mean Qmax of 22.1 ± 7.2 ml/s versus Rezum at 16.82 ± 2.27 ml/s at 12 months (PMID 40263139). Symptom scores may improve while objective flow remains inadequate. Both pieces of information are in the literature — only one appeared in the marketing.

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Category C: Controlling the Narrative

12. Ghost-written papers and reviews. The practice of ghost-writing — where industry-employed writers produce manuscripts that are then signed by academic physicians — has been documented in multiple medical specialties. In urology, the opportunity exists wherever a new device requires rapid evidence generation.

13. KOL development programs. This is long-term investment in influence. Companies identify promising young surgeons early in their careers — often trainees or early-career faculty — and cultivate them through early adoption programs, grants, speaking opportunities, and inclusion in advisory boards. By the time these surgeons become department heads, they have spent fifteen years building a relationship with a device brand. Their advocacy feels authentic because, from their perspective, it is.

14. Industry-funded "patient advocacy groups." Organisations that appear to represent patients independently are sometimes substantially funded by device manufacturers. These groups produce "patient education" materials, influence policy discussions, and lobby payers — all while presenting as independent voices.

15. Social media influencer programs for urologists. Device companies increasingly offer grants, travel, and recognition to physicians who are active on social media, in exchange for content that showcases their devices. These relationships are not always disclosed.

16. Sponsored symposia disguised as independent education. At every major urology congress — EAU, AUA, ESOU — a parallel universe of satellite symposia runs alongside the scientific programme. These are funded by industry, staffed by paid speakers, and often indistinguishable to attendees from independent scientific sessions. They are, functionally, advertising.

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Category D: Institutional Capture

17. "Centers of Excellence" as sales certificates. Rezum, UroLift, and GreenLight laser all offer "Centers of Excellence" designations to high-volume adopting institutions. The criteria are almost invariably volume-based: perform enough procedures with our device to qualify. There is no outcome requirement, no independent quality audit, no patient satisfaction threshold. These programmes are sales incentives with medical-sounding names. Hospitals display them proudly; patients assume they represent clinical quality.

18. Conflicts of interest in guideline panels. An analysis of financial conflicts of interest across AUA clinical practice guidelines (Carlisle A et al., Eur Urol 2018) found that 59.3% of AUA guideline authors received at least one industry payment — across 13 guidelines evaluated, not limited to BPH. Guidelines carry enormous weight — a "Grade B recommendation" can shift practice nationally within months of publication. When the people writing those recommendations have financial ties to the companies whose products they are evaluating, the potential for bias is structural, not theoretical.

19. Industry funding of professional societies. Medical societies depend on industry for much of their operating budget — through sponsorship of annual meetings, educational grants, and advertising in journals. This does not make societies corrupt, but it does create an environment where openly challenging major sponsors is institutionally uncomfortable.

20. Device rep relationships with hospital purchasing. In many institutions, procurement decisions about which devices to stock are influenced by the relationships between device company representatives and hospital purchasing managers. Clinical effectiveness may be secondary to negotiated pricing, bundled contracts, and long-standing commercial relationships.

Pull Quote: "A 'Center of Excellence' for a medical device is not a quality award. It is a sales milestone. Patients deserve to know the difference."

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The Evidence They Don't Want You to See

In 2025, a landmark study was published in European Urology Focus using the Epic Cosmos database — the largest real-world administrative dataset in American healthcare, encompassing 420,611 BPH procedures performed across diverse clinical settings.

This was not a randomised controlled trial with carefully selected patients, industry-defined endpoints, and 12-month follow-up. This was the real world: all patients, all surgeons, all institutions, tracked over five years.

The results were unambiguous:

Treatment	5-Year Retreatment Rate
HoLEP / ThuLEP (enucleation)	4.4%
TURP / Open Prostatectomy	7.1%
MISTs (Rezum, UroLift, Aquablation, etc.)	14-17%

(Reference: PMID 41558957, European Urology Focus 2026)

The durability gap is not small. Compared to enucleation, MISTs carry a 3-4× higher retreatment rate at five years. For a patient making a once-in-a-lifetime treatment decision, this is not a marginal difference — it is clinically decisive.

The same Epic Cosmos dataset (PMID 41558957) also illuminates what happens when MIST procedures fail: managing post-MIST failures is not straightforward. Anatomical distortion from implants (UroLift) or scarring (Rezum, iTind) makes subsequent enucleation more technically demanding. The retreatment burden falls on patients and healthcare systems that were never informed it was coming.

The common thread: when industry controls the research agenda, short follow-up hides long-term failure. When real-world data emerges at five years and beyond, the durability advantage of enucleation becomes undeniable.

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The Ejaculation Trade-Off: An Honest Discussion

It would be intellectually dishonest to dismiss the ejaculation argument. It is real, and it matters to many patients.

HoLEP, like TURP, results in retrograde ejaculation (ejaculate entering the bladder) in a majority of patients — rates vary by technique and experience, but typically range from 70-90%. Many MISTs, by contrast, preserve antegrade ejaculation. For sexually active patients who are not yet resigned to this outcome, this is a meaningful difference.

The question — and this is precisely where informed consent becomes crucial — is whether that difference justifies a 3-4× increase in retreatment risk.

The PROCEPT BioRobotics-funded study (Bouhadana et al., J Sex Med 2020) found that ejaculation was patients' top priority. But consider how the study was framed: patients were asked to rank priorities before receiving detailed information about retreatment rates, durability, and the consequences of repeat surgery. When patients understand that choosing ejaculation preservation with a MIST gives them a roughly 1-in-6 chance of needing another procedure within five years — potentially a more complex procedure due to post-MIST anatomy — many make different choices.

Informed consent for BPH treatment should sound something like this:

"Option A preserves ejaculation but carries approximately a 15% chance of requiring further surgery within five years. Option B results in retrograde ejaculation in approximately 80% of cases but has a less than 5% chance of requiring retreatment."

In my experience, across thousands of consultations in dozens of countries, when patients are given all the data — not the curated version — a substantial proportion choose durability. They were not anti-MIST; they were simply never offered the complete picture.

Pull Quote: "The informed consent conversation for BPH should include: 'With this treatment, you have a 1-in-6 chance of needing another surgery within five years.' How many patients hear those words today?"

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My Own Research: What the Data Shows from Thousands of Cases

My own published work provides a reference point from which to evaluate the current landscape.

In 2019, our group published the technique of en bloc HoLEP with early apical release in World Journal of Urology — Saitta G, Becerra JEA, Del Álamo JF, Llanes González L, Reinoso Elbers J, Suardi N, Gómez-Sancha F. "'En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia." World J Urol 2019;37:2451-2458. PMID 30734073. This described a systematized approach to complete anatomical enucleation along the capsular plane that provides consistent, reproducible outcomes. More recently, Iscaife A, Rodríguez Socarrás M, Talizin TB, Nahas WC, Fernandez Del Alamo J, Cuadros Rivera V, Gómez Sancha F. published "Contemporary results of En Bloc HoLEP for large prostates" (2025, PMID 40586952), demonstrating that the technique delivers durable outcomes even in the most challenging anatomical scenarios.

The capsular plane does not change with commercial trends. Anatomy is constant. What changes is whether the surgical community is taught to access it — and who funds that teaching.

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What Should Change: A Call for Transparency

This is not a call to abandon innovation. New technologies deserve evaluation. Some MISTs have genuine roles — in patients with specific anatomical or clinical profiles, or in healthcare settings where enucleation expertise is genuinely unavailable.

But the current system is failing patients by allowing commercial interests to dominate the information environment. Concrete changes would help:

1. Mandatory disclosure of ALL industry payments at scientific presentations. Not buried in a conflict-of-interest slide shown for three seconds, but prominently declared, in writing, in all congress materials.

2. Five-year minimum follow-up before guideline inclusion. BPH is a chronic condition. A treatment that looks good at 12 months but fails at 48 is not an advance — it is a deferral. Guidelines should require long-term durability data.

3. Independent funding for comparative effectiveness research. The BPH evidence base is disproportionately funded by device companies. Public funding bodies — NIH, NIHR, European Commission — should prioritise head-to-head, long-term comparison studies with no industry involvement.

4. Patient decision aids that include retreatment rates. Every shared decision-making tool for BPH treatment should present 5-year retreatment rates prominently, alongside ejaculation and continence outcomes.

5. "Centers of Excellence" based on outcomes, not volume. If these programmes continue, their criteria should include independent outcome audits, patient satisfaction measures, and complication rates — not procedure counts.

6. Conflict-of-interest thresholds for guideline panel membership. Physicians with declared financial relationships to companies whose products are under guideline review should be excluded from voting on those recommendations — or at minimum, their declarations should be published alongside each specific recommendation they influenced.

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Conclusion: The Capsular Plane Doesn't Lie

I am not writing this to condemn innovation, criticise colleagues who use MISTs, or suggest that device companies are uniformly malign. The medical device industry has delivered extraordinary advances. Some of my closest professional relationships are with industry scientists and engineers.

But after more than 10,000 en bloc HoLEP procedures, after training urologists on five continents, after reviewing every major dataset on BPH treatment durability, I have an obligation to say what the evidence shows clearly:

The most durable surgical treatment for BPH — by the largest real-world dataset ever assembled — is laser enucleation. Its retreatment rate at five years is 4.4%. The next best option, TURP, is 7.1%. The MISTs that dominate current marketing and commercial investment carry rates of 14-17%.

These numbers are not industry estimates. They are not cherry-picked from favourable trials. They are drawn from 420,611 real procedures, in real hospitals, in real patients.

I should be transparent: my career is built on enucleation. I have every professional incentive to advocate for HoLEP. I invite the reader to set aside my perspective entirely and examine the data independently. The Epic Cosmos database was not compiled by enucleation advocates — it is a neutral, administrative dataset of 420,611 procedures. The numbers speak without me.

Every patient deserves to know these numbers before they make their decision. Every surgeon has an obligation to present them — regardless of which company paid for last year's CME programme, which device rep sends the holiday gifts, or which "Center of Excellence" plaque hangs in the waiting room.

The capsular plane is a consistent anatomical boundary. Navigate it correctly, and you restore function durably. It does not care about business models, quarterly earnings calls, or marketing slogans.

That's the $30 billion question, answered honestly.

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References

1. PMID 41558957 — Epic Cosmos 420,611 procedures: 5-year BPH retreatment rates by modality — European Urology Focus, 2026

2. Bouhadana D et al. — Patient-reported outcomes and ejaculation as primary priority in BPH treatment — Journal of Sexual Medicine, 2020 (PROCEPT BioRobotics-funded)

3. PMID 30734073 — Saitta G, Becerra JEA, Del Álamo JF, Llanes González L, Reinoso Elbers J, Suardi N, Gómez-Sancha F. "En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia." World J Urol 2019;37:2451-2458

4. PMID 40586952 — Iscaife A, Rodríguez Socarrás M, Talizin TB, Nahas WC, Fernandez Del Alamo J, Cuadros Rivera V, Gómez Sancha F. "Contemporary results of En Bloc HoLEP for large prostates." 2025

5. Amparore D et al. — "Temporary implantable nitinol device for benign prostatic hyperplasia-related lower urinary tract symptoms: over 48-month results." Minerva Urol Nephrol 2023;75(6):743-751. PMID 37350585

6. McVary KT, Roehrborn CG et al. — "Rezūm Water Vapor Thermal Therapy for Lower Urinary Tract Symptoms Associated With Benign Prostatic Hyperplasia: 4-Year Results From Randomized Controlled Study." Urology 2019;126:171-179. PMID 30677455

7. Roehrborn CG et al. — "Five year results of the prospective randomized controlled prostatic urethral L.I.F.T. study." Can J Urol 2017;24(3):8802-8813. PMID 28646935

8. Carlisle A et al. — "Financial Conflicts of Interest Among Authors of Urology Clinical Practice Guidelines." Eur Urol 2018;74(3):427-429. PMID 29747945

9. PMID 40263139 — Matched pair analysis: HoLEP vs. Rezum — objective flow rate (Qmax) outcomes at 12 months

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About the Author

Dr. Fernando Gómez Sancha is a urologist and Medical Director of ICUA (Instituto de Cirugía Urológica Avanzada) at Clínica CEMTRO, Madrid, Spain. He is internationally recognised as one of the world's leading experts in en bloc holmium laser enucleation of the prostate (HoLEP), with more than 10,000 procedures performed. He has trained surgeons in over 50 countries and has published extensively on laser enucleation technique, outcomes, and the learning curve. Disclosures: Dr. Gómez Sancha is a consultant and proctor for Quanta System (laser manufacturer), has a collaborative agreement with Richard Wolf (endoscopy), and holds stock options in Andromeda Surgical (robotic HoLEP). These relationships are disclosed in the interest of full transparency — the same standard this article calls for across the field.

Twitter/X: @fgomsan

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This article represents the author's independent clinical and scientific perspective. All claims are referenced to peer-reviewed literature or public data sources. The author welcomes critical engagement and correction of factual errors.

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© 2026 Dr. Fernando Gómez Sancha. Reproduction for educational purposes permitted with attribution.

Live En Bloc HoLEP at EAU 2026: The New Kid is En Bloc

March 14, 2026 · London · EAU 2026 · Royal Free Hospital / ExCeL London

 

Today I had the extraordinary honour of performing live en bloc HoLEP surgery at the Royal Free Hospital in London, broadcast in real time to the main auditorium at ExCeL London during the EAU 2026 Congress.

The session — "The New Kid is En Bloc" — demonstrated the en bloc enucleation technique live, with no cuts or edits, while thousands of urologists watched every step on the big screen.

There is no greater validation of a surgical technique than performing it live, in real time, in front of your peers from around the world. The packed auditorium was a testament to the growing interest in en bloc HoLEP as the next evolution of prostate enucleation.

 

What Makes Live Surgery Special

• Complete transparency: Every step visible, every decision explained in real time
• No editing: The audience sees exactly what happens — successes and challenges alike
• Interactive teaching: Moderators and audience can ask questions during the procedure
• Peer validation: When thousands of colleagues watch you operate, the technique speaks for itself

Thank you to the European Association of Urology, the Royal Free Hospital team, Cook Medical, Richard Wolf and Quanta System for making this possible. And thank you to every urologist who was in that auditorium — your interest and enthusiasm are what drive this field forward.

The surgery was a success. The patient is doing well. And en bloc HoLEP continues to prove its place as a game-changing technique in prostate surgery.

Cook Medical Dinner at EAU 2026: The New Kid is En Bloc

March 13, 2026 · London · EAU 2026 · Stratford Hotel, Olympic Park

Last night I had the privilege of presenting "The New Kid is En Bloc: Translating Holmium Laser Physics into Surgical Mastery" at the Cook Medical dinner during EAU 2026 in London.

I shared the podium with Dr. Leye Ajayi, Consultant Urological Surgeon at St John & St Elizabeth Hospital, who delivered an insightful talk on pulse modulation and the Magneto holmium laser technology.

Key Topics Discussed

• En bloc HoLEP technique: Tips, tricks, and how understanding holmium laser physics translates directly into surgical outcomes
• Magneto technology: Advantages in hemostasis and tissue management during enucleation
• The future of holmium laser enucleation: Where the technique and technology are heading

The evening brought together a fantastic group of urologists for lively discussions over dinner. We even raffled copies of the En Bloc HoLEP manual among the participants — always a pleasure to share knowledge beyond the operating room.

Thank you to Cook Medical and Quanta System for organising this memorable event, and to Alan Loughnane and the entire MedSurg Division team for their support.

As Dr. Leye Ajayi wrote on LinkedIn: "Honoured to share the podium with Dr. Fernando Gómez Sancha who gave us an incredible insight, together with tips & tricks on performing en bloc technique for HoLEP."

Looking forward to today's live surgery demonstration at the Royal Free Hospital!

My take on abstracts on Enucleation

March 14, 2026 · London, United Kingdom
41st Annual Congress of the European Association of Urology (EAU26) · ExCeL London

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Dr. Fernando Gómez Sancha · ICUA – Instituto de Cirugía Urológica Avanzada · Clínica CEMTRO, Madrid · March 2026

Introduction

The 41st Annual EAU Congress brought together over 10,000 urologists in London. Among the sessions that caught my attention most, Abstract Session 21 — "Enucleation is enucleation: Comparing efficacies across technologies" — delivered exactly what its title promised: a clear, evidence-based confirmation that endoscopic enucleation of the prostate (EEP) has matured beyond the debate of which laser to use.

I reviewed all 35 abstracts presented at EAU26 that focused on prostate enucleation. What follows is my personal reading of the most relevant findings — and why, in my view, they consistently reinforce HoLEP as the benchmark technique against which all others should be measured.

1. Miniaturisation Has Level-1 Evidence Now

Two independent randomised controlled trials — the MILES trial (A0353) from Sechenov University and A0357 — compared a 22F miniaturised resectoscope (MiLEP) against the standard 26F instrument for laser enucleation. The results were strikingly consistent:

• Enucleation efficiency: equivalent in both arms
• Operative time: no significant difference
• Functional outcomes at 1 and 3 months: comparable
• Early stress urinary incontinence (SUI): 6.5% with 22F vs 29.5% with 26F (p=0.04)

This is the finding of the congress for enucleation surgeons. Two RCTs showing a fourfold reduction in early SUI with the smaller sheath — without any compromise in efficacy — elevates miniaturisation from expert opinion to solid evidence.

From a HoLEP perspective, this is particularly relevant. The holmium laser is perfectly compatible with 22F sheaths, and the anatomical enucleation technique does not require a large working channel. The data from these trials should accelerate the adoption of miniaturised instruments across the field.

2. "Enucleation is Enucleation" — The Data Agree

Multiple abstracts across Session 21 and the Expert-Guided Poster sessions compared different energy sources for enucleation: HoLEP, ThuLEP (pulsed Thulium:YAG), GreenLEP, AEEP. The conclusion is consistent with what experienced enucleation surgeons have been saying for years:

"Enucleation is enucleation." The anatomical plane, not the laser wavelength, determines outcomes.

Abstract P0584 — a prospective non-randomised trial comparing pulsed Thulium:YAG versus Holmium:YAG for enucleation — found equivalent functional results, with Thulium showing marginal advantages in haemostasis. A decade of surgical trends at LMU Munich (A0345) documented the complete transition from TURP to laser enucleation as the institutional standard for BPO management.

My interpretation: the technology choice matters less than the surgeon's command of the anatomical enucleation technique. This is the argument I make in every HoLEP training course I run — the laser is just the tool. The surgical concept is what we are teaching.

3. Tranexamic Acid in Anticoagulated Patients: Practice-Changing Data

Abstract P0731 — a multicenter prospective study by the EAU Endourology Section — is one of the most clinically applicable findings from the entire congress. With 932 patients across 30 centres:

• Intraoperative TXA reduced bleeding complications: OR 0.17 (p<0.001)
• Haemostasis time was significantly shorter in TXA groups
• No impact on functional outcomes at 3 months
• Independent risk factors for bleeding: ongoing anticoagulation (OR 2.93), dual therapy (OR 4.31), longer operative time

For surgeons operating on patients who cannot safely discontinue antithrombotic therapy — a growing population — this evidence provides a practical, low-cost intervention that significantly reduces haemorrhagic risk. Intraoperative tranexamic acid deserves a place in our routine protocol for anticoagulated patients undergoing EEP.

4. Patients and Surgeons Don't Prioritise the Same Things

The ENUC-TR study (P0723) — a multicenter cross-sectional survey across four Turkish urology clinics involving 82 urologists and 622 patients — surfaced a finding that should make every enucleation surgeon pause:

• Surgeons ranked continence as the top priority (45.7%)
• 35.9% of patients placed ejaculation preservation among their top 3 priorities
• 14.8% of urologists did not inform patients about ejaculatory dysfunction before surgery
• 30.9% did not discuss erectile function

No surgeon ranked ejaculation as a first priority. But more than one in three patients did. This is a disconnect we need to address — not by changing what we do surgically, but by changing how we talk to patients before we operate.

In my practice, I discuss ejaculatory outcomes explicitly with every patient considering enucleation. Retrograde ejaculation is an expected consequence in most cases, and patients deserve to understand this — and to factor it into their decision.

5. Bladder Neck Contracture: Predictable and Preventable

A retrospective analysis of 1,740 patients (P0733) identified independent risk factors for bladder neck contracture (BNC) following laser enucleation of the prostate:

• Preoperative urinary tract infection: OR 4.42 (p<0.01) — significant risk factor
• Larger anteroposterior prostatic diameter: OR 0.44 (p<0.01) — protective
• Prediction model AUC: 0.736

The practical message is clear: screen for and treat urinary tract infection before enucleation.

6. The HoLEP Perspective: Why These Results Matter

Reading these abstracts as a HoLEP surgeon and international trainer, what strikes me most is the coherence of the evidence. Every major finding from EAU26 on enucleation reinforces the same message: the technique is what matters.

HoLEP — performed with proper anatomical dissection, with or without a miniaturised sheath, in large or small prostates, in anticoagulated or standard patients — continues to deliver the most robust and reproducible outcomes in the literature.

The debate is no longer HoLEP vs TURP. It's not even HoLEP vs ThuLEP or AEEP. The debate is: how do we train more surgeons to enucleate properly?

At ICUA, we have been running international HoLEP training programmes for surgeons from over 50 countries. What these abstracts confirm is that the investment in anatomical enucleation training — regardless of the laser platform — is the most impactful intervention we can make for patients with benign prostatic obstruction.

Conclusions

1. Miniaturisation (22F) is now evidence-based: same efficacy, significantly less early SUI.
2. "Enucleation is enucleation": anatomical technique, not laser choice, determines outcomes.
3. Intraoperative TXA significantly reduces bleeding risk in anticoagulated patients — a practice-ready finding.
4. Patients care more about ejaculatory function than surgeons assume — pre-operative counselling must improve.
5. Preoperative UTI is a modifiable risk factor for bladder neck contracture — screen and treat before enucleating.

The evidence from EAU26 does not complicate the picture — it clarifies it. Enucleation, done right, is the standard. The challenge now is disseminating the technique.

— Dr. Fernando Gómez Sancha, March 2026
Medical Director, ICUA · Clínica CEMTRO, Madrid
icua.es | @fgomsan

Signing my book - the book sold out!

March 14, 2026 · London, United Kingdom
41st Annual Congress of the European Association of Urology (EAU26) · ExCeL London

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One of the most rewarding moments of EAU 2026 in London was the official presentation and signing of The En Bloc HoLEP Manual — and every single copy sold out.

This manual has been years in the making. It distills more than a decade of experience with en bloc holmium laser enucleation of the prostate, covering everything from surgical anatomy and technique to tips for managing complex cases, large glands, and patients on anticoagulants.

The goal was always to create a practical resource — not just theory, but a step-by-step guide that a urologist could take into the operating room. The kind of book I wished I'd had when I was learning the technique myself.

Why now?

The interest in anatomical enucleation has never been higher. At this year's EAU alone, 35 abstracts were presented on prostatic enucleation techniques. Major centres worldwide are transitioning from TURP to laser enucleation, and the demand for structured training resources continues to grow.

Seeing colleagues from so many countries come to the signing — from Latin America, Asia, Europe, the Middle East — was a powerful reminder that this technique is truly global. And that sharing knowledge is just as important as developing it.

What's inside

• Surgical anatomy of the prostate relevant to en bloc enucleation
• Step-by-step technique with annotated images and diagrams
• Tips and tricks from over 10,000 enucleation procedures
• Managing difficult cases: large glands (>200g), previous BPH surgery, anticoagulated patients
• Learning curve guidance for urologists starting their enucleation journey

Thank you to the EAU for hosting the event, to the publisher for making it happen, and most of all to every colleague who took the time to come by. Your interest and enthusiasm are what make this work worthwhile.

The manual is available for those who couldn't attend — you can find it in amazon and it will be ready to ship in a matter of days!

Presentation of the Manual of En bloc HoLEP at the EAU 26 Congress

After more than two decades performing and teaching en bloc HoLEP across 50+ countries, I am proud to announce that "The En bloc HoLEP Manual" is finally here.

This comprehensive manual covers everything I have learned over 10,000+ laser enucleations — from the anatomical principles that underpin the technique to advanced tips for the most complex cases. It is designed for every urologist who wants to learn or master anatomical en bloc enucleation.

WHERE TO GET IT

EAU26 London — This Friday, March 13th

Limited copies available at the Wisepress stand. I will be there for a "Meet the Author" session — come say hello!

Amazon — Available in Days

The book will be available on Amazon in both English and Spanish within the next few days.

WHAT'S INSIDE

• Step-by-step anatomical en bloc enucleation technique

• Tips for large glands (100g+) and complex cases

• Morcellation strategies and troubleshooting

• Learning curve guidance — from first cases to mastery

• Detailed anatomical illustrations

• My personal experience from 10,000+ procedures in 50+ countries

This book represents my life's work in prostate surgery. I hope it helps the next generation of urologists provide better outcomes for their patients.

See you at EAU!

Originally posted January 30, 2026

Today I performed three live surgical cases for the InaSER Masterclass in Bali, Indonesia. The session was dedicated to teaching advanced endoscopic enucleation techniques. We utilized the Quanta System laser for all procedures. The live cases demonstrated the HoLEP method in a real clinical environment. Attendees from the region observed the surgical workflow directly. I explained specific technical steps during the intervention, focusing on apical dissection and mucosal preservation. The event served as a practical training module for local urologists. The cases were recorded and made available for review in my youtube channel.

Originally posted January 29, 2026

I conducted a 2-day workshop on HoLEP at Ngoehra Public Hospital in Bali, Indonesia. The course included lectures on technique simplification and hands-on training for the participants. Participants practiced the dissection steps using the Holmium laser system. Local urologists from the region attended the event to learn new skills. We covered patient selection and procedural nuances in detail. The session focused on practical experience sharing among the attendees. The hospital facilities supported the training requirements effectively. Several complex cases were discussed during the theoretical part. The feedback from the participants was positive.

Originally posted January 25, 2026

I spent the weekend at Hill Clinic teaching urologists from Turkey en bloc HoLEP. The group included new friends interested in the technique. We focused on the recent advances in Anatomic Enucleation using the Holmium laser. I explained how the procedure is simplified and how to perform early apical dissection. Live surgical cases were discussed to clarify the steps for mucosal preservation. The participants asked specific questions regarding the laser settings and tissue handling.

We completed the training session on Sunday afternoon.