Last updated: March 2026
If you have been recommended prostate surgery with HoLEP, or are considering it, it is natural to want to know exactly what will happen. This article describes the patient experience step by step — before, during, and after the procedure — as we carry it out daily in our operating theatre, after more than 10,000 enucleations.
Before surgery
The consultation: initial assessment
When a patient comes in for consultation, we ask them to bring a blood test with PSA and a urine analysis, and to arrive with a comfortably full bladder (we recommend not urinating for two hours beforehand and drinking 3–4 glasses of water an hour before). In the waiting room, we provide the IPSS questionnaire to assess symptom severity.
In the consultation room, we take a clinical history, review the blood work, perform an ultrasound of the urinary tract with a full bladder, and carry out a flowmetry test. We then check for post-void residual urine with ultrasound. With all this information, we can advise the patient on whether they need medical treatment, monitoring, or whether surgery should be considered.
When do we recommend surgery?
There are two situations. The first is when there is a mandatory indication for surgery: urinary retention requiring a catheter, bladder stones, prostatic bleeding, recurrent infections, or kidney damage. In these cases, surgery should not be delayed.
The second is when the patient meets surgical criteria without a mandatory indication: symptoms affect quality of life and medical treatment is insufficient. In these cases, I always tell the patient that it is important they are genuinely convinced that the operation is necessary, or at least advisable. Operating on a man who is not convinced is a bad idea — if something does not go perfectly, the burden of blame falls on whoever made the recommendation. When the patient actively participates in the decision, they navigate the postoperative period much better.
Medications you need to stop
If you take anticoagulants or antiplatelet agents, it is essential to communicate this. Depending on the type of medication:
- Aspirin, clopidogrel (Plavix), ticlopidine: stop 7 days before surgery.
- Warfarin/acenocoumarol: stop 3 days before and start low-molecular-weight heparin as directed by your surgeon.
- Direct oral anticoagulants (rivaroxaban, apixaban, dabigatran): stop according to the specific protocol for each drug.
It is very important to coordinate this with your urologist and, if necessary, your cardiologist. The holmium laser has excellent haemostatic properties — in our series, the transfusion rate is below 1% — but proper preparation is essential.
The day of surgery
The patient is admitted in the morning, fasting (no food, drink, or smoking for 6 hours beforehand). Surgery is usually scheduled for the afternoon. Before the procedure, the anaesthetist will visit to explain the type of anaesthesia and answer any questions.
During the procedure
Anaesthesia
We generally use spinal anaesthesia (intradural), which numbs the body from the waist down. The patient is awake but feels absolutely nothing in the surgical area. A mild sedative is given so you feel relaxed, and you will likely doze off lightly during the procedure. In some cases, general anaesthesia is used — your anaesthetist will explain the advantages of each option.
How long does the operation take?
It depends on prostate size. In our series of 754 patients:
- Normal-sized prostates (<120 g): 25 minutes of enucleation + 5 minutes of morcellation + haemostasis = approximately 45–60 minutes total.
- Large prostates (≥120 g): 40 minutes of enucleation + 13 minutes of morcellation + haemostasis = approximately 70–90 minutes total.
These times reflect an experience of thousands of procedures. A surgeon at the beginning of their learning curve will require more time, but this does not affect safety or long-term outcomes.
What does the surgeon actually do?
An endoscope is inserted through the urethra to the prostate area. Using the holmium laser, the boundary between the adenoma and the urinary sphincter (the "white line") is marked to protect continence from the very first moment. The adenoma is then gradually peeled off the prostatic capsule circumferentially — like peeling an orange — until the entire piece is pushed into the bladder. There, it is fragmented with an instrument called a morcellator and suctioned out for histopathological analysis.
Finally, haemostasis is checked (ensuring there are no bleeding points) and a urinary catheter is placed.
After surgery
The first few hours
When you leave the operating theatre, you will have a urinary catheter with a slow continuous irrigation to keep the urine clear. After spinal anaesthesia, there is no pain — the only common complaint is being unable to move your legs for a couple of hours until the effect wears off. Most patients do not require painkillers.
The following morning: catheter removal
We follow an early catheter removal protocol that has proven very effective. The nurse flushes the catheter to clear any small clots that formed overnight, removes the catheter, and fills the bladder with saline. The patient gets up and urinates — usually 3–4 times during the morning. If all goes well, discharge is around midday.
With this protocol, approximately 5% of patients have difficulty voiding after removal. In those cases, the catheter is reinserted and the patient goes home with it, returning to the clinic 1–2 days later for removal. If we left the catheter in for 48 hours, 99% would void without trouble — but we prefer early removal so that 95% of patients do not spend an extra day with a catheter unnecessarily.
Discharge medication
We prescribe an anti-inflammatory for one week (usually dexketoprofen 25 mg three times daily) with a gastric protector, and a prophylactic antibiotic for one week. We advise patients to avoid constipation (no straining during bowel movements) and to drink plenty of fluids.
The first few weeks: what is normal
It is important to know what to expect so you do not worry unnecessarily:
- Pinkish urine or mild bleeding for the first few days — this is normal and gradually clears.
- Passing small clots or yellowish particles — these are normal remnants from the healing process.
- Stinging when urinating at the beginning and end of the stream — transient, resolves within days.
- Urgency and frequency — irritative symptoms may persist for up to 3–4 months. Interestingly, the first two to three weeks are often the best, and then urgency and nocturia reappear before improving definitively.
One-month review
We see the patient after one month. Most already notice a very significant improvement in urinary flow. Some irritative symptoms may persist and will continue to improve.
Three-month review
At three months, the vast majority of patients feel very well. Irritative symptoms are resolved or nearly resolved. We perform a flowmetry, symptom questionnaire, and PSA test. If all is well, we recommend an annual PSA review with their GP.
Results: the numbers that matter
In our published series of 754 patients operated with the en bloc technique:
- Urinary flow: from 8 ml/s preoperatively to 24–28 ml/s postoperatively — an immediate and dramatic improvement.
- IPSS (symptom score): from 24 preoperatively to 3 at 12 months — virtually symptom-free.
- PSA reduction: 93–94% — confirming complete adenoma removal.
- Stress incontinence at 6 months: 0.15% (prostates <120 g) and 0.9% (≥120 g).
- Transfusion rate: below 1%.
- Hospital stay: 24–48 hours in most cases.
An important note for follow-up: PSA
After HoLEP, PSA should drop below 1 ng/mL. If at any future check-up your PSA rises above this level, it needs to be investigated — it may indicate residual adenomatous tissue or, in some cases, prostate cancer requiring further study. It is crucial that your GP knows that the reference value after an enucleation is not the standard "below 4 ng/mL" but below 1 ng/mL.
When can I return to normal life?
- Light domestic activity: from the day after discharge.
- Office work: after 2–3 days.
- Driving: after one week.
- Gentle exercise (walking): from day one. Intense exercise: after 4 weeks.
- Sexual activity: after 3–4 weeks.
- Long-distance travel: after 2–3 weeks, ensuring adequate fluid intake and regular voiding.
At ICUA we will explain the entire process in a personalised consultation. In-person in Madrid or international video consultation.
📞 +34 91 435 28 44 · ✉ icua@icua.es
Scientific references
- 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
- Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol. 2019;37:2451-2458. PubMed
- 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
- Gauhar V, Lim EJ, Fong KY, et al. Influence of early apical release on outcomes in endoscopic enucleation of the prostate: results from a multicenter series of 4392 patients. Urology. 2024;187:154-161. DOI
