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 400 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 our 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, Gómez Sancha F, 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

What Is HoLEP? A Complete Guide to Holmium Laser Enucleation of the Prostate

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

The prostate grows with age. It is as inevitable as grey hair. From the age of 30, prostatic tissue begins to develop what we call benign prostatic hyperplasia (BPH) — a growth that, in many men, will eventually cause bothersome symptoms or complications that seriously affect quality of life.

If you are reading this article, you have probably been diagnosed with a prostate problem and are looking for information about your surgical options. I will explain clearly what HoLEP is, why I consider it the best available surgical treatment for BPH, and what we have contributed at ICUA to refine this technique over more than 20 years.

When does the prostate become a problem?

Symptoms appear when prostatic growth compresses the urethra and makes it difficult for urine to flow. The patient notices a weak stream, difficulty starting urination, a feeling of incomplete bladder emptying, and waking up several times at night. In more advanced cases, serious complications arise: acute urinary retention (complete inability to urinate, requiring a catheter), recurrent urinary infections, prostatic bleeding, bladder stones, and even kidney damage.

I often tell my patients that there are two types of cases: those with a mandatory indication for surgery — retention, stones, kidney failure, bleeding, recurrent infections — and those who are not obliged to undergo surgery but meet the criteria for us to recommend it. In both scenarios, it is important to understand that BPH is a progressive disease. The bladder deteriorates if the obstruction is not adequately treated, and there is a window of opportunity to act before bladder damage becomes irreversible.

What is HoLEP?

HoLEP stands for Holmium Laser Enucleation of the Prostate. It is a surgical technique that uses a high-precision laser to separate the prostatic adenoma (the tissue that has grown and causes obstruction) from the prostatic capsule, and remove it completely.

The orange analogy: The prostatic capsule is the peel, and the adenoma — the tissue that grows and obstructs — is the flesh. HoLEP separates the flesh from the peel completely, in exactly the same way a surgeon does with their fingers during a classic open operation, but without any abdominal incision. Everything is performed through the urethra.

The technique was originally developed in New Zealand in the 1990s by Drs Gilling and Fraundorfer. Since then, it has undergone enormous evolution, with multiple technical refinements that have improved outcomes and made it easier to learn. The clinical guidelines of both the European Association of Urology (EAU) and the American Urological Association (AUA) recommend it as a standard option, regardless of prostate size.

How is HoLEP different from other techniques?

There are many options for prostate surgery, and it is perfectly normal for patients to feel confused. The fundamental difference lies in the concept: enucleation is not the same as resection or vaporisation.

Transurethral resection (TURP) is the classic technique. An electrical loop cuts the adenoma into small chips, like carving a statue from the inside. The problem is that it never removes all the tissue — remnants are always left behind that can regrow. And in large prostates, the procedure becomes very lengthy, increasing the risk of bleeding and other complications. The long-term retreatment rate with TURP ranges from 10 to 15%.

GreenLight laser vaporisation destroys prostatic tissue by evaporating it. It is very safe in terms of bleeding, but has a limitation: the tissue disappears, leaving no specimen for laboratory analysis, and in large prostates the procedure is very slow and often incomplete.

Enucleation (HoLEP) follows the natural anatomical plane between the adenoma and the capsule, separating them completely. It uses the same principle as classic open surgery — which for decades was the gold standard for large prostates — but without incisions, without transfusions, and with a much faster recovery. And crucially: the entire adenoma is removed, so the retreatment rate is below 2%.

The conceptual difference is this: TURP and vaporisation work from the urethra outward, carving a channel through the adenoma. HoLEP works from the outside in, peeling the entire adenoma off the capsule. It is an anatomical, complete, and definitive operation.

What is en bloc enucleation?

The original HoLEP technique separated the adenoma into two or three lobes that were pushed into the bladder separately. It was effective, but technically demanding with a long learning curve.

Over the course of my experience, first with the GreenLight laser and subsequently with the holmium laser, I developed a technique we call en bloc enucleation with early apical release and sphincteric mucosal preservation. Instead of dividing the adenoma into fragments, we separate it from the capsule in a single piece — en bloc, like peeling an entire orange.

The procedure begins by marking the boundary between the apex of the adenoma and the external urinary sphincter — what we call the "white line." From there, we release the sphincter from the adenoma early, protecting it from the very first moment of the surgery. We then dissect the adenoma circumferentially until the entire piece can be pushed into the bladder, where it is fragmented with an instrument called a morcellator for extraction.

This technique has several proven advantages:

It is faster. A randomised controlled trial published in 2025 directly compared en bloc enucleation with the conventional lobe-by-lobe technique. The en bloc approach reduced enucleation time from 74 to 62 minutes and total operative time from 95 to 79 minutes, with lower laser energy consumption. A prospective study of 600 patients also confirmed that the three-lobe technique is significantly slower than en bloc.

It better preserves continence. Early release of the sphincter minimises traction throughout the surgery. In our series of 754 consecutive patients operated with this technique, published in World Journal of Urology in 2025, the stress incontinence rate at 6 months was 0.15% for prostates under 120 grams and 0.9% for those above. These are extraordinarily low figures.

It is easier to learn. A study published in Translational Andrology and Urology showed that with the en bloc technique, a beginner surgeon reaches a reasonable level of competence in 20–30 cases, compared to 50 needed with the classic three-lobe technique. A study from the University of Mannheim with 500 consecutive en bloc cases confirmed continuous improvement in efficiency even after hundreds of procedures.

It works equally well for prostates of any size. In fact, the larger the prostate, the more efficient en bloc enucleation becomes. In our published series, enucleation efficiency in large prostates was 3.1 grams per minute — double that of smaller prostates. We have operated on prostates weighing 300, 400, and even 500 grams with this technique, with excellent results.

Who is HoLEP suitable for?

One of HoLEP's great advantages is that it has no prostate size limit. While TURP has a practical ceiling around 80 grams and other treatments such as Aquablation have a limited range, HoLEP can treat prostates of any volume. It is the only endoscopic technique that truly replaces open surgery, with the same efficacy but without its drawbacks.

It is especially indicated for:

• Large prostates (over 80–100 grams), where other endoscopic techniques fall short.
• Patients on anticoagulants, thanks to the excellent haemostatic properties of the holmium laser. The transfusion rate in our series is below 1%.
• Patients with indwelling catheters, who need a definitive solution to their obstruction.
• Patients with bladder stones, which can be treated in the same session with the same laser.
• Any patient seeking a definitive solution with the lowest possible retreatment rate.

The importance of surgeon experience

I must be honest about one thing: HoLEP is a technique that depends heavily on the skill and experience of the surgeon. Having the laser is not enough — you need to know how to use it. The learning curve exists, although modern techniques such as en bloc enucleation have shortened it significantly.

How can you tell whether your surgeon has the necessary experience? There are a few reasonable questions you can ask: how many enucleations have they performed, whether they have published their own results, whether they train other surgeons in the technique. A surgeon who teaches others has, by definition, a deep mastery of what they do.

At ICUA, we have been performing laser prostatectomies since 2003 and enucleations since 2007. We have accumulated over 10,000 prostatic enucleations. I described the GreenLight en bloc enucleation technique (GreenLEP) published in World Journal of Urology in 2015, and the en bloc HoLEP technique with early apical release published in 2019. Our series of 754 consecutive cases using this technique was published in 2025. We are co-authors on the REAP registry, the largest global multicentre database for prostatic enucleation, comprising 6,193 patients from 10 centres in 7 countries. We have trained surgeons from over 60 countries in our operating theatres in Madrid and Sofia.

What can you expect after HoLEP?

Most patients are admitted in the morning, undergo the procedure under spinal anaesthesia (numb from the waist down), and can go home the following day, without a catheter in most cases. Urinary flow improves immediately and dramatically — in our series, peak flow rate goes from 8 ml/s before surgery to 24–28 ml/s afterwards.

Recovery is swift: normal daily activities within 2–3 days, although some urinary symptoms such as urgency or mild burning may persist for a few weeks. These are transient and resolve progressively.

After HoLEP, PSA should drop below 1 ng/mL — an important marker for follow-up that reflects the completeness of the enucleation. In our series, the PSA reduction was 93–94%.

The vast majority of patients are able to discontinue all prostate medication and never require further surgery.

Would you like to know if HoLEP is right for you?

Request a consultation at ICUA · Clínica CEMTRO, Madrid — or a video consultation if you are outside Spain.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Because as I tell my patients: you don't have to be the first to have surgery, but you shouldn't be the last either.

Scientific references

1. Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol. 2019;37:2451-2458. PubMed
2. Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
3. Gomez Sancha F, Rivera VC, Georgiev G, et al. Common trend: move to enucleation — Is there a case for GreenLight enucleation? Development and description of the technique. World J Urol. 2015;33:539-547. DOI (Open Access)
4. Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients to refine endoscopic anatomical enucleation of the prostate (REAP). World J Urol. 2023;41:3033-3040. PubMed
5. Gauhar V, Lim EJ, Fong KY, et al. Influence of early apical release on outcomes in endoscopic enucleation of the prostate: results from a multicenter series of 4392 patients. Urology. 2024;187:154-161. DOI
6. Rücker F, Lehrich K, Böhme A, et al. A call for HoLEP: en-bloc vs. two-lobe vs. three-lobe. World J Urol. 2021;39:2337-2345. DOI
7. Wenk MJ, Hartung FO, Egen L, et al. The long-term learning curve of HoLEP in the en-bloc technique: a single surgeon series of 500 consecutive cases. World J Urol. 2024;42:436. PubMed
8. Li P, Wang C, Tang M, et al. The en bloc method is feasible for beginners learning to perform HoLEP. Transl Androl Urol. 2023;12(3):379-390. PubMed Central

Related articles

→ HoLEP vs TURP, GreenLight, Aquablation & Open Surgery: An Evidence-Based Comparison → 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 → Does HoLEP Affect Erections and Sexual Function?