If medicines are no longer controlling urinary symptoms caused by an enlarged prostate, your urologist may discuss a procedure to remove the prostate tissue blocking the flow of urine. Two established options are HoLEP (holmium laser enucleation of the prostate) and TURP (transurethral resection of the prostate).
Both procedures are performed through the urethra, without an external incision, and both aim to remove the prostate tissue responsible for urinary obstruction. So what is the difference between them, and is one better than the other?
The answer depends on factors such as prostate size, anatomy, medical history, bleeding risk, recovery priorities and surgical expertise. For a broader understanding of BPH and its treatment options, see our guide to BPH and enlarged prostate.
HoLEP and TURP: The Main Difference
The biggest difference is how the obstructing prostate tissue is removed. In TURP, the surgeon uses a specialised instrument passed through the urethra to cut away the prostate tissue that is narrowing the urinary passage. The removed tissue is taken out in small pieces.
HoLEP uses a holmium laser to separate the enlarged inner portion of the prostate from the surrounding prostate capsule. The tissue is then moved into the bladder, broken into smaller pieces and removed using a specialised instrument.
In simple terms, both procedures remove the tissue causing obstruction, but HoLEP uses an enucleation technique with a laser, while TURP removes the obstructing tissue by resection.
*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.
HoLEP vs TURP at a Glance
| Feature | HoLEP | TURP |
|---|---|---|
| Full name | Holmium laser enucleation of the prostate | Transurethral resection of the prostate |
| How tissue is removed | Laser enucleation followed by removal of the tissue | Resection of obstructing tissue using an electrosurgical instrument |
| External incision | No | No |
| Urine flow improvement | Substantial improvement | Substantial improvement |
| Suitable prostate size | Can be used across a broad range, including large prostates | Commonly used for moderate-sized prostates; very large prostates may favour an enucleation approach |
| Bleeding considerations | Generally favourable perioperative bleeding profile | Effective and established, but bleeding remains an important surgical consideration |
| Durability | Durable symptom and flow improvement | Durable symptom and flow improvement |
| Learning curve | Requires specific technical expertise and experience | Widely established technique with extensive clinical experience worldwide |
Which Procedure Works Better?
For the most important measures—urinary symptoms and urine flow—both procedures can provide substantial and durable improvement. Current evidence does not show that TURP is simply “better” or that HoLEP is universally superior. Instead, HoLEP has demonstrated similar mid- to long-term effectiveness to TURP, while offering some perioperative advantages.
Studies comparing the two procedures have found comparable improvements in measures such as the International Prostate Symptom Score (IPSS) and maximum urinary flow rate over longer follow-up periods.
For larger prostates, HoLEP can be particularly useful because the enucleation technique allows the surgeon to remove a substantial amount of obstructing tissue without relying on prolonged conventional resection.
Why Might HoLEP Be Considered for a Large Prostate?
One of the major strengths of HoLEP is that it is not restricted to relatively small or moderate-sized prostates. Because the surgeon can enucleate the enlarged inner prostate tissue along the natural surgical plane, HoLEP can be used for large prostates as well as smaller ones.
This can be important when a man has substantial prostate enlargement and significant urinary obstruction. With conventional TURP, the amount of tissue that can be safely removed during one procedure is more limited, and the procedure becomes less practical as prostate size increases. For very large prostates, other approaches—including enucleation techniques such as HoLEP—may therefore be considered.
What About Bleeding?
Bleeding is a consideration with any procedure that removes prostate tissue. HoLEP uses a holmium laser that provides tissue cutting and coagulation. This contributes to a favourable bleeding profile and is one of the reasons laser enucleation has become an important alternative to TURP.
Current evidence reviewed in the EAU guidelines indicates that HoLEP has a more favourable perioperative profile than TURP, although both procedures are established surgical treatments. This does not mean that HoLEP eliminates bleeding risk. Every surgical procedure has potential complications, and individual risk depends on factors such as prostate size, medical conditions, medications and surgical technique.
Which Has a Faster Recovery?
Recovery is influenced by the individual procedure, prostate size, catheter duration, hospital protocols and the patient's overall health. Both HoLEP and TURP are performed through the urinary passage, so neither requires an abdominal incision.
Many patients can therefore return to normal activities relatively quickly compared with open prostate surgery. HoLEP may have advantages in some perioperative measures, including catheterisation and hospitalisation, although the exact recovery experience varies.
It is also normal to experience temporary urinary symptoms after either procedure. Increased frequency, urgency, mild burning or blood in the urine can occur during the early recovery period as the urinary tract heals. Recovery should therefore be judged over weeks rather than expecting urinary symptoms to disappear immediately after the procedure.
*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.
Is HoLEP More Difficult Than TURP?
HoLEP requires specialised technical training and has a recognised learning curve. The procedure involves identifying the correct tissue plane, enucleating the prostate and then removing the enucleated tissue. Experience can therefore have a meaningful effect on operative efficiency and complication rates.
TURP is also a technically demanding procedure, but it has been performed for many decades and is widely established. For a patient deciding between the two, the experience of the surgeon with the specific procedure is an important practical consideration. A theoretically attractive procedure may not be the best choice if the necessary expertise is not available.
Are the Results Permanent?
Both HoLEP and TURP can provide long-lasting relief from urinary obstruction. HoLEP may have an advantage in durability for some patients because a large amount of obstructing tissue can be removed through enucleation. Current evidence also shows favourable retreatment outcomes with HoLEP, particularly in studies involving larger prostates.
However, no prostate procedure guarantees that urinary symptoms can never return. Symptoms can be influenced by bladder function, urethral changes, ageing and other urinary conditions as well as recurrent prostate tissue growth.
How Do Doctors Choose Between HoLEP and TURP?
Rather than deciding solely on the basis of which procedure sounds more advanced, the urologist considers the overall clinical picture. Important factors include:
- Prostate size: Very large prostates may favour an enucleation technique such as HoLEP.
- Prostate anatomy: The presence of a median lobe and other anatomical features can influence procedure selection.
- Severity of obstruction: More significant obstruction may require a procedure capable of removing a substantial amount of tissue.
- Bleeding risk: Individual bleeding risk and use of blood-thinning medicines may influence the discussion.
- Previous treatment: Prior prostate procedures can affect the choice of subsequent treatment.
- Sexual priorities: Men should understand the likelihood of ejaculatory changes before treatment.
- Surgeon's experience: Expertise with the selected technique is an important part of treatment planning.
- Patient preference: Recovery expectations, treatment goals and willingness to accept possible side effects should be considered.
The Bottom Line
HoLEP and TURP are both established treatments for urinary obstruction caused by an enlarged prostate. The main technical difference is that TURP removes obstructing tissue by resection, while HoLEP uses a holmium laser to enucleate the enlarged inner portion of the prostate before removing it.
Both can substantially improve urinary symptoms and urine flow. HoLEP has the advantage of being suitable across a broad range of prostate sizes and may be particularly useful for large prostates. It also has a favourable perioperative safety profile, including less bleeding in many clinical comparisons.
TURP, meanwhile, remains an effective and well-established option, particularly for men with moderate-sized prostates. It has extensive long-term clinical experience and continues to be an important surgical treatment for BPH.
The choice should therefore not be reduced to “HoLEP is newer, so it must be better.” The better procedure for an individual patient depends on prostate size and anatomy, urinary obstruction, bleeding risk, sexual priorities, overall health and—very importantly—the surgeon's experience with the technique.
Discussing these factors before treatment can help you understand not only which procedure can relieve the obstruction, but also what to expect during recovery and what changes in urinary and sexual function may follow.
